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BUILDING HEALTHIER COMMUNITIES

A review of the Santnet2 Program

Cover photos: (1) Community-case management (2) Community health volunteer, specialized in both child and maternal health (3) A WASH friendly Community health volunteer (4) Community review meeting

MAY 2013
USAID/Santnet2 is implemented by RTI International, under the contract n GHS-I-01-07-00005-00, in partnership with CARE International, CRS, PSI, IntraHealth International and DRV.

Documentation submitted to USAID/Madagascar May 2013 Prepared for Robert Kolesar Contracting Officers Representative (COR) USAID/Madagascar
All images Santnet2 2008-2013 Report researched and written by Matthew Greenall.

TABLE OF CONTENTS
TABLE OF FIGURES GLOSSARY AND ABBREVIATIONS 1. INTRODUCTION 1 2 3
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About this report Methods

2.

A MODEL FOR BUILDING HEALTHIER COMMUNITIES

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Households, communities, and health in rural Madagascar Kaominina Mendrika Salama: a community-led health system

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SANTENET2 ACHIEVEMENTS: AN OVERVIEW OF RESULTS

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A community health program implemented at scale Results generated by the Kaominina Mendrika Salama system

4. UNDERSTANDING THE RESULTS OF SANTENET2: CRITICAL FACTORS AND LESSONS LEARNED 21


Critical success factors Lessons learned 21 26

WORKS CITED

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Building healthier communities: A review of the Santnet2 Program.

TABLE OF FIGURES
Figure 1: Rural housing and rice farming in the highlands, Amoroni Mania region 6 Figure 2: The Kaominina Mendrika salama model: placing families and communities at the center, and providing comprehensive support for better health 9 Figure 3: Map of coverage of KMs by recruitment phase 10 Figure 4: Two CHV in front of their community hut in Marofinaritra commune, SAVA region 12 Figure 5: Growth monitoring and childhood illness case management by CSBs and CHVs in program Communes, 2010-2012 18 Figure 6: Regular family planning users in the 800 KMS communes, served by CHVs and served by other sources 19 Figure 7: A CHV waits in her health hut. The timetable posted on the wall outside shows the times that she is available at the hut. However, CHVs are also happy to attend emergencies outside of hours 24 Figure 8: Mothers wait outside the community health hut in their village to have their young children weighed by the community health volunteer. Regular weighing of infants and children, often conducted alongside the provision of nutritional support and advice. 28

Building healthier communities: A review of the Santnet2 Program.

GLOSSARY AND ABBREVIATIONS


ARI CCDS (commission communale dveloppement de la sant) CHV CLTS Commune CSB (Centre de Sant de Base) CSP Fokontany FP HIV-AIDS HMIS KMs (Kaominina Mendrika salama) LPTM MSI/M PSI RDT RTI International WASH USAID Acute respiratory infection de Community Health Development Commission Community health volunteer Community led total sanitation Local administrative level in Madagascar Community health center Community supply point Lowest level of administration in Madagascar (equivalent to neighborhood or village) Family planning Human immunodeficiency virus/Acquired immune deficiency syndrome Health management information system Champion healthy community Long Term Permanent Method (contraceptive) Marie Stopes International/Madagascar Population Services International Rapid diagnostic test Research Triangle Institute International Water, sanitation and hygiene United States Agency for International Development

Building healthier communities: A review of the Santnet2 Program.

1. INTRODUCTION
ABOUT THIS REPORT
Peoples health is determined by many factors: by their knowledge and behavior, by the social and physical environment in which they live, and by their ability to access the services and support that can help them stay healthy and that can treat them when they fall ill. In Madagascar, almost 80% of the population lives in rural areas. Poor transport infrastructure further accentuates the limited access of much of the population to basic health, education and welfare services, and to clean water and effective sanitation. National health indicators confirm that the rural population in Madagascar lags behind. Rates of the main childhood illnesses (malaria, acute respiratory infections, and diarrhea), of malnutrition and of maternal mortality are all much higher than in urban areas. Rates of unwanted pregnancies are also higher in rural areas, placing a further burden on families health and quality of life (Institut National des Statistiques/Direction des Statistiques des Mnages, 2010; Institut National de la Statistique Ministre de l'conomie et de l'Industrie and ICF Macro, 2010). In developing Santnet2, USAID and RTI International set out with an ambitious plan: to work in partnership with over half of the rural population of Madagascar, to address the biggest health challenges they face. This report describes some of the principal results of the Kaominina Mendrika salama (KMs) approach, and describes some of the key lessons and recommendations for the future.

METHODS
This report was commissioned by RTI International and produced by an independent consultant. The report aims to: Describe the main program strategies and principal results of the Santnet2 program Draw conclusions about the relationship between Santnet2 interventions and changes, and the critical factors leading to or impeding improvements at community level Discuss the drivers of community ownership, motivation and confidence Draw broad lessons on the development of community health programming in Madagascar The description of results synthesizes information from a number of sources: Annual and semi-annual reports of Santnet2 Process and community based service data from program database Reports of evaluations and reviews of specific components of the Program conducted over the course of its implementation (these are referenced in this review) 3

Building healthier communities: A review of the Santnet2 Program. Interviews and focus groups conducted by the author with Program stakeholders (members of Community Health Development Commissions; community health workers; and community leaders and other stakeholders) in 4 Communes during March 2013 The interviews and focus groups conducted at community level were an invaluable means of putting the results of the Program in context. By identifying some of the principal strengths and weaknesses as perceived by these community level actors, they helped to structure the analysis of how the Program enables improvements now and how it could do more. Santnet2 staff also supported the analysis contained in this report, through their prompt responses to requests for data, through their suggestions regarding the principal questions to be investigated, and through their participation in a one-day analysis workshop conducted immediately after the fieldwork with the aim of analyzing the achievements and challenges of the Program.

Building healthier communities: A review of the Santnet2 Program.

2. A MODEL FOR BUILDING HEALTHIER COMMUNITIES


HOUSEHOLDS, COMMUNITIES, AND HEALTH IN RURAL MADAGASCAR
A typical rural Malagasy family lives, essentially, a subsistence lifestyle. Parents, and children when they are old enough, tend smallholdings of rice and other staples, as well as livestock. Rice paddies are irrigated through rain and sometimes diverted streams, and also provide water for drinking and washing for most of the rural population. Wood and charcoal provide the main source of cooking and heating fuel. Much of the housing is made from locally available materials such as clay, earth and straw. Most of the villages and hamlets in predominantly hilly rural areas are linked to larger markets and urban centers by paths and unpaved roads. While primary education enrollment is now almost universal, many of the older generation will not have benefited from the progress made in access in the past 50 years and at present, less than half the population attends secondary school and less than 10% obtains a high school diploma. Traditionally, the Malagasy population has dealt with health problems by resorting to self-medication and healers. Culturally, large families are highly valued. Well over half of pregnant women deliver their babies at home, with the support of family members or a traditional birth attendant. Access to some of the basic services and amenities that favor better health also remains limited. Only 15% of the population in rural areas has access to improved sanitation, and 34% to an improved water source (The World Bank, 2013). Although a functional primary health care infrastructure exists, over half of the rural population lives 5 kilometers or more than one hours walk from the nearest primary care center (CSB centre de sant de base). On top of this, Madagascar suffers from a critical health care worker shortage. There are estimated to be 0.15 physicians and 0.25 nurses or midwives per 1,000 members of the population, against a WHO-established norm of 2.28 workers per 1,000. Moreover, there is a particular shortage of specialists with some provinces having no specialist clinical capacity at all. Distribution of scarce health care workers is also problematic, since one third of ministry of health employees are based in the capital region, Analamanga (Kinfu, 2008; Cakir, 2013). Coverage ratios in rural areas are therefore considerably lower than those cited here. The combination of these particular circumstances particularly the traditional means for protecting health and obtaining care, and the environments in which they live, make Malagasy people in rural areas vulnerable to a range of preventable health problems. Children, particularly those under 5, are affected by respiratory infections, malaria and diarrheal disease. Together these account for a large proportion of the under-5 mortality rate, which currently stands at 72 deaths per 1000 live births. Malnutrition is another important factor for child survival: about half of under-5s are stunted and 22% have severe malnutrition. In addition, because women begin to have children at a young age (1/3 of women aged 15-19 are pregnant or are already mothers), one in five women has an unmet need for family planning, and fewer than half of births are attended by skilled personnel, Madagascar has a maternal mortality ratio of 498/100,000 live births (WHO, 2013; The World Bank, 2013; Institut National de la Statistique Ministre de l'conomie et de l'Industrie and ICF Macro, 2010).

Building healthier communities: A review of the Santnet2 Program.

KAOMININA MENDRIKA SALAMA : A COMMUNITY-LED HEALTH SYSTEM


Although there has been remarkable progress in population health in Madagascar in recent decades, there is still considerable room for improvements. The context within which the rural population lives demands an approach that on the one hand enables individuals, families and communities to better protect their own health, and on the other hand brings essential, good quality services closer to these communities. Santnet2, a five-year program funded by USAID and implemented by RTI International alongside a number of international and national partners, set out to scale up the Kaominina Mendrika salama (known as KMs, translated as champion healthy communes) approach in order to improve the health of millions of the most vulnerable people in Madagascar.

Figure 1: Rural housing and rice farming in the highlands, Amoroni Mania region

The KMs approach rests on three main pillars. The first is community-level action, and is based on the recognition that individuals, families and communities are the primary agents who can improve their own health. Community programs were implemented at the level of the Fokontany, the most decentralized administrative level, to inform and train people about a wide range of healthy behaviors and practices, including: protecting and cleaning water sources; developing better hygiene and sanitation practices; family planning; the importance of antenatal care; immunization of children; nutrition; detecting illness; and preventing common infections such as malaria. Community programs also supported collective action at community level, such as: to develop collective commitment to improving sanitation and eradicating open-air defecation; to manage and maintain improved communal water sources; to establish systems for transportation of medical emergencies to health facilities; and in some cases, to establish community health insurance mutual funds in order to reduce the impact of catastrophic health care expenditures. Collective efforts also provided communities with a platform to identify priorities and factors influencing health, and to discuss and agree the changes necessary to address these. Promotion of dialogue on gender equality was an important component of this work, as has been the selection and training of youth leaders mandated to promote adolescent reproductive health. It 6

Building healthier communities: A review of the Santnet2 Program. was also designed to enable communities to demand greater accountability from the authorities and providers responsible for promoting and protecting health. The community program component, which aimed to develop individual and community efficacy and leadership on health, was supported by a range of actors. These included radio broadcasters and community and faith based organizations mandated by Santnet2, as well as the different entities and actors that form part of the community health system, which is the second pillar of the KMs approach. This second pillar is built on the recognition that, in the current context, good quality health care services are out of practical reach of many millions of rural Malagasy people. The system therefore aims to extend this reach, as well as strengthening the availability and quality of existing services. The community health system developed with the support of Santnet2 has the following components: Community health development commissions (Commissions communales de dveloppement de la sant or CCDS). These committees, established at the level of the Commune (the next administrative level up from the Fokontany) are responsible for identifying health priorities, mobilizing community action on health, monitoring water, hygiene and sanitation activities, and supervising health service provision. Typically their members include the mayor or deputy-mayor of the commune, staff of the community health centers, other local leaders (including religious leaders) and community representatives. Santnet2 input includes support to establishment of the committees, and training of as well as support for regular planning and review meetings. Community health volunteers (CHV) are another cornerstone of the KMS approach. In order to extend the reach of community health centers (CSB) which are by and large based at Commune level, Santnet2 invested in training over 13,000 community health volunteers, mandated to conduct health promotion and provide basic health services in Fokontany that are more than 5 kilometers from their nearest CSB. This system was designed to increase access to health care for remote communities on the Services offered by maternal health CHVs one hand, and to reduce the Information and distribution of family planning methods and focus on postpartum proportion of simple cases being FP treated at CSBs on the other hand. Messages on the prevention of sexually Continuing the emphasis on transmitted infections/HIV-AIDS community engagement, community Safe motherhood (antenatal care, members themselves at Fokontany intermittent preventive treatment, nutrition, iron supplementation) level selected the CHVs. Child-CHVs Level 2 maternal health CHVs, as above plus: focus on child health services such as Injectable contraceptive (depo provera) growth monitoring, nutrition advice Services offered by child health CHVs and support and, in most cases, Essential Nutrition Actions community case management of fever, Growth monitoring and promotion acute respiratory infection and Expanded Program on Immunization diarrhea. Since 2010, CHVs with promotion appropriate training have been Level 2 child health CHVs, as above plus: authorized to use rapid diagnostic Malaria, diarrhea, and acute respiratory infection prevention and case management tests (RDT) to diagnose malaria. 7

Building healthier communities: A review of the Santnet2 Program. Maternal health CHVs focus on early detection of pregnancy, distribution of iron-folic acid supplements, and family planning. CHVs also play the important role of identifying serious cases for referral to CSBs, and in promoting community health through, for instance WASH and CLTS programming. Community supply points (CSPs) were established to ensure a steady, reliable supply of essential commodities and medicines that can be purchased by CHVs for sale to community members. Products available from these CSPs include: infant/child formulation treatments for diarrhea, pneumonia and malaria; and a range of family planning methods. Products are often subsidized and designed to be affordable even to those with very little ability to pay. Health management information system (HMIS). This system enables an effective tracking of performance of community-based service provision by CHVs, and of other aspects of progress. Because managers of CSBs and community health committees are involved in validating periodic reports from CHVs, the HMIS also ensures the linkage between services provided by CHVs and CSBs and enables a commune-wide view of progress. Another crucial aspect is that the system permits monitoring of stocks of products held by CHVs and the CSPs, thereby triggering re-ordering and reducing the risks of stock-outs. Tools for quality improvement and accountability; Training, supervision and technical assistance. The components listed above are supported to be operational through the development and provision of tools, such as reporting formats, job aids and communication materials, as well as through regular training and supervision provided by Santnet2 staff, and staff of implementing partners (international and local NGOs) contracted to provide this support. Among the tools are two important innovations, designed to strengthen community engagement and to promote accountability. The Quality Index is a mechanism for scoring communes according to their level of service provision and compliance with system standards for instance, CHV coverage levels, capacity of CHVs in terms of skills and equipment, service usage, and efficiency of the CSP, as well as timeliness, completeness and accuracy of monthly reporting. The second tool, the Social Quality tool, builds on the Community Score Card approach introduced by the World Bank, and is focused on building community level empowerment, ownership and accountability at grass roots (Fokontany and Commune) level.
Components of the Quality Index and Social Quality tools Quality Index Social Quality

Coverage of remote Fokontany with CHVs Skills of CHVs Availability of resources, equipment and tools Existence of community level action (such as planning, awareness raising, CSPs, reporting) Service usage indicators

Raising community awareness on rights Local capacity to identify and understand community health priorities and needs Local capacity to address community health priorities and needs Quality of health services measured against objective standards and in terms of levels of community satisfaction Service usage indicators

The Quality Index is conducted every six months for all KMS communes via a review of documents and statistics supplied by communes and CHVs.

Social quality measurement is conducted by Commune actors, through community meetings and participatory reviews by the CCDS.

Building healthier communities: A review of the Santnet2 Program. The third pillar of the KMS approach focuses the efforts of the first two pillars with a view to achieving strategic results in a number of priority areas related to maternal health, family planning, and child survival: hence the focus on training CHVs to deliver community case management services that will have an impact on uncomplicated cases, an emphasis on identification and referral of complicated cases, and on water, sanitation and hygiene promotion at community level (using the community led total sanitation/CLTS approach). Pulling all these strands together also required a considerable amount of management and coordination. The Santnet2 team worked closely with three subcontracting organizations and thirteen Malagasy grantee NGOs, who were contracted and trained to deliver supervision and technical assistance to actors at Commune and Fokontany level. In addition the Santnet2 team collaborated with other programs involved in supporting community health, particularly PSIs social marketing program to supply CSPs, existing child nutrition programs, and CHV initiatives implemented by JSI under USAID funding, as well as a large Global Fund-supported initiative.

Figure 2: The Kaominina Mendrika salama model: placing families and communities at the center, and providing comprehensive support for better health

Building healthier communities: A review of the Santnet2 Program.

3. SANTENET2 ACHIEVEMENTS: AN OVERVIEW OF RESULTS


A COMMUNITY HEALTH PROGRAM IMPLEMENTED AT SCALE
Santnet2 set out to implement the KMS approach at considerable scale. This section presents some of the principal inputs and outputs at implementation level. 800 communes covered, in 16 of the 22 regions and 72 of the 119 districts Santnet2 was implemented in 800 of Madagascars 1,579 Communes, in 16 of the 22 regions and 72 of the 119 districts in the country. In each of these communes, which have a total population of 11 million, Santnet2 supported the process of setting up the Community health development commissions (CCDS), training their members and supporting their review and planning activities. 14,546 members of CCDS, of which 2,245 were women, participated in this process. Using the Social Quality approach, these CCDS also conducted 1,887 participatory performance evaluations, with almost all of the CCDS conducting this process at least twice.
Phase 1: January 2009 (225 Communes) Phase 2: November 2009 (249 Communes) Phase 3: February 2010 (326 Communes)

Figure 3: Map of coverage of KMs by recruitment phase

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Building healthier communities: A review of the Santnet2 Program.

Over 998,270 community members were involved in evaluating health services and developing priorities The first series of community evaluation meetings, conducted in 6,850 Fokontany across the 800 Communes, involved the participation of over 998,270 community members including 550,575 women. This created a strong basis for community ownership of the KMS approach. As of the time this analysis was conducted, two thirds of Fokontany had conducted a second community evaluation meeting and the third round of meetings had been initiated in 175 Fokontany. 807 community supply points established Community supply points (CSP) were established in all of the KMs communes, and were supplied with the tools and skills to manage and reorder supplies in an effective and timely way. CHVs placed in 5,758 Fokontany situated over 5 km from a community health center Within the 800 KMS communes, Santnet2 placed CHVs in I am caring for people all Fokontany located over 5 km from a community health who would not normally choose to go to get center (representing a total population of 5,940,000). treatment at a CSB 13,086 CHVs were selected for the role by community members in each Fokontany and were trained by Santnet2 CHV with around half trained to act as maternal health CHVs and half as child health CHVs. Following initial training 12,395 (95%) were evaluated as qualified to work without further training. 11,413 CHVs were operational by the end of the project, an attrition rate over 4 years of 8%. A large proportion of those leaving the role did so because they left the community where they were based. This rate compares favorably with the attrition rate of health care professionals. Over 90% of operational CHVs were level 2 CHVs (in other words, for child health CHVs they were able to carry out community case management, and for maternal health CHVs they were able to administer longlasting injectable contraceptives). Level 1 CHVs are for the most part newly recruited to replace departing CHVs.

Distribution of CHVs CHV type Child health volunteer level 1 Child health volunteer level 2 (incl. community case management) Maternal health volunteer level 1 Maternal health volunteer level 2 (incl. injectable contraceptive) Total Number of CHVs operating both on maternal and child health: Trained
670 6,190 697 5,529 13,086

Operational
350 5,602 339 5,122 11,413 3,776

Ongoing performance monitoring of CHVs, which is based on compliance with case management and service delivery criteria, numbers of people served, cases managed and/or regular FP users, has showed that well over 80% of CHVs were rated as highly performing, and only 3-4% performing at unsatisfactory levels. Performance monitoring conducted during initial and refresher training also indicates that over the period 2009-2013 CHVs are increasingly rated as

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Building healthier communities: A review of the Santnet2 Program. highly performing, with the proportion of low performing CHVs decreasing year on year from a high of 16% in 2009 to 5% in 2013. 3,552 health huts established In addition, 3,552 health huts were either built or restored in the Fokontany where CHVs were placed. These health huts provide a location for CHVs to keep equipment and supplies and to receive community members for advice and community case management. Where health huts are established, this can be considered an indicator of community commitment, since they are established using community resources. The Santnet2 team estimates that the cost of constructing a hut can reach USD200, a considerable amount given the limited financial resources available in remote communities.

Figure 4: Two CHV in front of their community hut in Marofinaritra Maroantsetra SAVA region

Community led total sanitation in 3,732 villages The CLTS process was triggered in 3,732 villages located in 1,780 Fokontany. WASH (water, sanitation and hygiene) activities were implemented more widely through local radio and community mobilization activities.

68 of the KMs communes and 688 Fokontany supported to set up community insurance mutual We have tried to set up a funds mutuelle but no-one has Mutual health funds were piloted in a sub-set of communes joined yet CCDS member and Fokontany. They are currently operational in 67 of these communes and 678 of the Fokontany. However, many individuals interviewed for the purposes of this review appeared skeptical about the purpose of these funds, and it has been reported elsewhere that community members who pay into the funds subsequently expect reimbursal if they do not use the funds for medical purposes suggesting that they are perceived by some as saving rather than insurance schemes (Castle, 12

There is a mutuelle but I am not a member yet it is too expensive. We are asked to pay by individual rather than by household. Community member

Building healthier communities: A review of the Santnet2 Program. 2011). More recently, the Santnet2 team have received indications that enrolment in mutuelles is increasing in certain regions and, in parallel, CSB service usage has increased. However further research is needed to verify these observations. Emergency evacuation procedures established in 6,388 Fokontany Given the large distances to health facilities and the poor transport infrastructure, communities were also supported to develop local agreements and procedures designed to ensure evacuation of medical emergencies to health facilities. Although communities have, for many years, carried emergency cases by stretcher or other means of transport, these procedures are expected to address not just transport but also coverage of emergency health care costs. 7,812 persons were evacuated through community systems. Out of which 3,741 were pregnant women and 1,272 newborn were evacuated Wide reaching awareness-raising and information provision 10,313 local radio broadcasts on health in Fiscal Year (FY) 2011, 12,849 in FY 2012, and 7,607 in FY 2013 (October 2012 to March 2013), reaching over 350,000 people each year. These broadcasts covered a range of topics including maternal and child health; malaria; reproductive health and family planning; water, sanitation and hygiene; and community engagement. 1,051 youth leaders established Although the primary focus of the KMS approach is to improve maternal and child health, adolescent reproductive health is equally a priority; consequently Santnet2 worked with the CCDS to select youth leaders in each of the Communes. The role of these leaders is to provide advice to young people; some CHVs also provided basic advice on reproductive health to young people when requested. Development of a pool of local field support technicians In order to support community mobilization and supervision processes Santnet2 trained 146 field support technicians, thus creating a pool of good quality advice and supervision at decentralized level. Technicians were given increasing training and responsibility over time, based on six-monthly training. Their roles at present range from technical supervision of CHV, monitoring monthly reporting, promoting key activities such as CLTS and WASH, promoting dialogue on gender issues, facilitating community participation, and promoting youth reproductive health activities. RESULTS GENERATED BY THE KAOMININA MENDRIKA SALAM A SYSTEM The outcomes and impact of Santnet2 can be assessed in a number of ways. This section begins by discussing the performance of CCDS and local health care providers as evaluated by means of the Quality Index and Social Quality tools. Following this, summary statistics on service provision and usage are provided. PROGRESS IN RELATION TO QUALITY INDICES AND REGULAR MONITORING As described above, the KMs model includes a number of procedures to ensure regular monitoring of the performance of the community health system. Particular emphasis has been placed on the active involvement of the CCDS and of community members themselves in these monitoring processes, as a means of increasing ownership and generating direct accountability 13

Building healthier communities: A review of the Santnet2 Program. between health care providers and local decision makers and communities. Quality has also been measured through regular monitoring of CHVs by the CCDS members, by technical advisors, and through the use of the Quality Index.

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Building healthier communities: A review of the Santnet2 Program.

Strong trend toward improved satisfaction with health care provided by CHVs and CSBs, according to the Social Quality tool All of these measures have indicated improvements in performance over the course of Santnet2 support. Community based evaluations of the performance of health facilities, for instance, indicated improvements in all three of the principal domains: quality of care (i.e. attitudes, compliance and availability of health care workers), medicines (perceived effectiveness and availability), and environment (e.g. cleanliness of health center and health huts, availability of the necessary equipment, confidentiality). While the main purpose of the Social Quality tool is to catalyze discussions and planning for change at community level rather than to give an objective measure of improvements, the aggregate scores are There is a lack of qualified personnel in the CSB useful since they indicate trends in the levels Long queues and waiting times of perceived satisfaction with services. Scores for both medicines and environment during the latest evaluations (ending April 2013) were considered good, with 70% of respondents in all communes expressing satisfaction with medicines and 85% with the environment. Although there was also an improvement in levels of satisfaction with Community members quality of care, the proportion of satisfied respondents was 58%, leaving some room for improvement. A comparison with scores achieved during the implementation of Community Score Cards in 2008 also suggests a trend toward improved satisfaction. Community satisfaction with the performance of CHVs was measured according to the same variables, and also shared a trend toward improved satisfaction. By March 2013, 70% of community respondents said they were satisfied with the quality of care. The proportion satisfied with medicines was 61% and 58% were satisfied with environmental aspects.

Treatment in CSBs is of poor quality, it depends on how much you are willing to pay CSB services are good but often no-one is there The CHVs are always available and nearby. Much better and more available and take more time than the CSB we no longer have to go to the CSB which is good since we never know if a doctor will be present.

People trust us and do not hesitate to ask us for advice. We have become a role model for the community. When we did latrine awareness we started by building them at our place following all the norms, so as to show a good example. Even the most marginalized can get help from me The prices [of medicines] are manageable everyone is prepared to pay and can pay. People like to buy [medicines] from the CHVs CHVs

The third component of the Social Quality tool is the self-evaluation by the CCDS of its own performance. The majority of CCDS also indicated at the last evaluation that they had become more effective, with particularly high scores for their efforts in relation to gender, collaboration with partners, and support to the CHVs, and in the establishment of effective emergency evacuation policies. CCDS were somewhat self-critical of their performance in following up and sharing information with the community and many noted this as an area for improvement.

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Building healthier communities: A review of the Santnet2 Program. Improvements in key externally-measured quality of service indicators The results of monitoring conducted by means of the Quality Index add weight to the positive indications provided by the Social Quality tool. Based on a weighted scoring of coverage of remote Fokontany by CHVs, skills of CHVs and availability of equipment and resources required for their work (all assessed through regular supervision), community engagement and levels of service usage, the Quality Index provides an overall score for each of the Communes in the KMS program. When the Quality Index was first applied in April 2011, 48% of Communes were evaluated as satisfactory on the Quality Index, 26% were evaluated as average and 26% were evaluated as unsatisfactory. By April 2013, the proportion evaluated as satisfactory the highest tier in the Index was 94%, with no Communes judged to be unsatisfactory. A particularly steep improvement in performance was observed in the service usage category. Only 40% of communes were satisfactory on this benchmark in April 2011, but by September 2011 the proportion of satisfactory communes was 70%. The proportion of Communes served by satisfactorily skilled CHVs also improved considerably over the period, from 63% in April 2011 to 94% in September 2012. 84% of Communes were reported as having a satisfactory level of coverage by CHVs of remote Fokontanys within the Commune. During the qualitative work carried Medicines are expensive in the pharmacies... out as part of this review a number of Our biggest problem is paying for treatment [the CHV] products are affordable. respondents commented on the dont know of any child that has died because importance of effective CSPs, and their mother could not afford medicine from the many hinted that there had in the past CHV Community member been a problem of stock outs, particularly for certain products and The CSP often comes to review our reports medications. It was not possible to [because the doctor is not doing so] to see how we are doing. establish how regular these stock outs When there are stock outs [of medicines] it where or their cause; however it was undermines our credibility clear that when they occur they have CHV a major impact on the effectiveness of We noticed that the CHVs had not made any orders the community health system. Part of from the CSPs, and we discovered that it was the reason for this is the physical because they did not have the means to pay for the accessibility of products that can be products CCDS bought from the CHVs; another important aspect is that products bought from CHVs (primarily supplied by the CSPs) are more affordable and therefore financially accessible to the population. Moreover the managers of the community supply points often play a role in supervising and monitoring the CHVs, particularly when the local health center employees are not adequately fulfilling this task. Another important insight was that, some CHVs had not continued selling medicines and products because they lacked the funds they needed to purchase their stock of products and medicines from the CSPs. Although CHVs received a start-up stock, it is possible, given the high incidence of poverty and occasionally lengthy stock-outs that their initial capital was depleted, hampering their ability to re-stock.

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Building healthier communities: A review of the Santnet2 Program. SERVICE PROVISION AND USAGE INDICATORS While the quality indicators described above both internally and externally evaluated provide useful summary measures of progress, Santnet2 also sought to achieve measurable impacts on the health status of the rural Malagasy population. Given Santnet2s focus on strategic results in the area of maternal and child health, data on service usage and on objectively verifiable changes at community level are the principal means of measurement. Steady increase in levels of community case management of childhood illnesses by CHVs There are problems in the CSBs. The graphs in Figure 5 below show the increased But since the community health involvement, year on year, of CHVs in delivering volunteer started we can get services. community case management services for three Community member priority childhood illnesses (ARI - acute respiratory infections; diarrhea; and fever), as well as for growth When I arrived in this CSB there were far more sick children. monitoring (red columns). While the increase is partly This has changed thanks to the attributable to the increasing number of child health CHVs and good planning. We CHVs qualified to provide community case are now better than average [for child illnesses] management, data also show an increase in the average CSB doctor number of cases seen by individual CHVs, reaching a mean of 48 cases per CHV during 2012. The mean number of babies weighed by each CHV in 2012 was 257. The graphs also show CHVs taking on an increased proportion of case management and growth monitoring tasks when compared to the local health centers (CSBs, blue columns), suggesting that the introduction of community case management is resulting not only in net increases of children being treated and weighed, but is also reducing the burden on CSBs this is desirable since it can enable health care professionals in CSBs to focus on more serious cases. Growth monitoring has also enabled earlier detection and referral of children at risk of malnutrition; statistics and anecdotal reports suggest that the instance of cases of malnutrition has begun to decrease. In addition, while there is no data on the influence of CHVs on vaccination rates, many CHVs and CCDS members reported that they had indeed observed increased uptake of childhood immunization. Given the role of CHVs in providing contact for remote communities with basic health services, it is likely that these service usage increases have benefited previously marginalized communities, therefore providing an important equity promotion function.

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Building healthier communities: A review of the Santnet2 Program.

Figure 5: Growth monitoring and childhood illness case management by CSBs an d CHVs in program Communes, 2010-2012

Improved diagnosis and treatment of malaria Since the introduction of rapid diagnostic testing, CHVs have been able to effectively manage malaria at community level, ensuring more rapid treatment and reducing the burden on health facilities. During 2012 67,461 malaria cases were diagnosed and treated. Referrals of complicated cases were also effective, with CHVs reporting 9,949 referrals to health facilities. These numbers suggest that CHV are making an effective contribution to the fight against malaria in Madagascar

My child tested positive and he was better in three days the medicine is very affordable Without [the CHV] being there, my child could have died my child had malaria, but he also presented danger signs he sent me to the CSB to get appropriate care. The CSB gave my child good care, [and afterwards] the CHV followed up and monitored my childs health Community members

Progression in the volume of family planning provided by CHVs One of the principal roles of maternal health CHVs is to provide a range of family planning options; a very large Ive learned so much. I could never have proportion of the CHVs have now achieved level 2 which imagined someone like means that they can offer long-lasting injectable me would be able to give an injection. You can feel contraception (Depo Provera) as well as condoms and pills. the impact many The number of regular users of family planning (any modern women are using family contraceptive method) served by CHVs has increased planning now. steadily over the course of the project. In 2010, CHVs served Maternal health CHV 42,226 regular users around 6% of the users in the 800 Communes covered by Santnet2. In 2011, this proportion had increased to 16% (102,847 users served by CHVs) and at the latest count CHVs were serving 164 091 regular users, 11% of all users in the project Communes. 66% of these users use injectable contraceptives, and 28% use the pill. Each maternal health CHV currently serves an average of 40 regular users of contraceptives. Although the number of regular users has

18

Building healthier communities: A review of the Santnet2 Program. increased in every region, the rates are very varied, with the lowest region having 3 regular users per CHV and the highest region having 47 regular users per CHV, confirming that there is a way to go in changing attitudes towards and access to family planning in some regions. At present 18% of all injectables and 29% of all contraceptive pills distributed at community level by CHVs or CSBs in the 800 KMs Communes are distributed through CHVs.

Figure 6: Regular family planning users in the 800 KMS communes, served by CHVs and served by other sources

In July 2010, Marie Stopes International/Madagascar (MSI/M) and Santnet2 signed a partnership agreement under which CHVs in the KMs communes would refer clients to MSI/M sites for long-term permanent methods (LTPMs). Collaboration with MSI/M aimed to provide LTPM through There are not many family planning users [in mobile clinics to women of reproductive age in KMs our area]. People want communes. MSI/M provided additional training on children, and there are rumors about family promoting LTPM and referring women of reproductive age planning that it makes to health facilities or MSI/M mobile clinics for LTPM. you put on weight and The Santnet2 and MSI/M teams designed actions intended Maternal health CHV to expanding the range of FP methods available at the community level as well as improving access to the methods. The mapping of MSI/Ms LTPM sites conducted November 2012 showed that MSI/M mobile teams visited 454 KMs communes. The information was shared with CHVs to enable them to refer women who choose LTPM as their FP method. Improving access to antenatal care and skilled delivery Access to skilled antenatal care is particularly challenging, since maternal health CHVs are not able to provide the full range of care achieving results in this area therefore requires effective referrals to the CSBs. During 2012, 61,261 pregnant women were managed by CHVs, and 30,664 of these referred to CSB for ANC by the CHVs. CHVs also provided

become ill.

We dont go to the health facility to deliver because most of the time the midwife is not present the facility is too far away you risk having your baby on the way. I had mine on the road. Community members I noticed a change in the women who started to use family planning. When they become pregnant they go for antenatal care. Women now want to go to the hospital to give birth but the midwife and doctor are often away so women still give birth at home Maternal health CHV

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Building healthier communities: A review of the Santnet2 Program. Iron Folic Acid supplements to 11,892 pregnant women and supported another 7,200 to receive these supplements through referral to CSBs. Another key intervention, intermittent preventive treatment for malaria, was provided to all of these referred pregnant women. Respondents interviewed for the purposes of this review confirmed the impression that while uptake of antenatal care is increasing, there has been less progress in the uptake of skilled delivery of babies. During 2012, CHVs reported that 963 cases of pregnant women exhibiting danger signs had been identified and referred to CSBs for management. However, for women who live a long distance from health facilities, the preference in many parts of the country is still to deliver at home, with the help of a traditional birth attendant.
In one Fokontany we Progress in water, sanitation and hygiene and built latrines but no-one other health promotion wants to use them Community stakeholders, CCDS members and CHVs CCDS member interviewed as part of this review almost universally stated People have mosquito that the single most important intervention still required to nets but they do not use improve health in their communities was the provision of them some are afraid safe drinking water. However, they also reported strong they may catch fire. I see nets in their houses still progress in the area of sanitation and hygiene in most cases, in their packages. although in some areas the use of latrines remains limited. Child health CHV These verbal reports are borne out by the data reported by CHVs to Santnet2: over 25,000 latrines have been built, serving over 68,000 households. By April 2013, thanks to CLTS (Community Led Total Sanitation) efforts led by the CCDS and CHVs, 1,041 Fokontany had been certified as opendefecation free.

Many CHVs include other aspects of health promotion in their work, in particular by supporting the CCDS to conduct periodic awareness campaigns. There is limited data on the effect of this work, and while a number of CHVs reported to this review that they had seen progress, some underlined that behaviour change is hard to achieve for instance in relation to indoor cooking or mosquito net usage. Implementation of emergency evacuation procedures As noted above, a large number of Fokontany developed improved evacuation procedures for medical emergencies. Implementation of these procedures is likely to be under-reported; however, those reports that were received by the Santnet2 team record 7,812 instances of emergency evacuations in these Fokontany, half of which involved transportation of pregnant women to ensure safe attended deliveries. On the other hand, the results of qualitative research conducted for this review suggest that while at a basic level most Fokontany already practice evacuations, in many cases there is not yet an added value to the system such as, for instance, the incorporation of local solidarity funds to cover the costs of these evacuations.

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Building healthier communities: A review of the Santnet2 Program.

4. UNDERSTANDING THE RESULTS OF SANTENET2: CRITICAL FACTORS AND LESSONS LEARNED


The results described in the previous chapter illustrate the tangible outcomes of the strengthening and expansion of the community health system in Madagascar. Clearly these results cannot be wholly attributed to the investments of Santnet2, since they also depend on the considerable efforts of other support programs, local health centers, CCDS members, and community members themselves. This chapter discusses in more detail the critical factors that have influenced these results, whether they emanate directly from the support provided by Santnet2, or from the other actors and stakeholders.

CRITICAL SUCCESS FACTORS


The existence of a strongly integrated, multidimensional system One of the central principles of the KMs approach is that it links a number of different interdependent components the CCDS (which focuses on planning and governance), the CSB (facility-based service delivery), the CSP (to ensure availability of health products), awarenessraising and programming including through the youth leaders, the CHVs (bringing key services and support closer to communities), and the community itself. These are also underpinned by the provision of training, equipment, tools and support from the broader Santnet2 team including the locally contracted technical assistance NGOs. While each of these components adds specific value, the collective contribution is worth much more than the sum of its parts. While, to an extent the CHVs enable a displacement of simple services from CSBs to the local level, program data indicate that they have also enabled an overall increase in service usage. However, the existence of CHVs does not remove the need for effective provision in CSBs indeed it emphasizes the need since one of the roles of CHVs is to refer expectant mothers and children for specialized services when they need them. The interdependence of the different components is also exemplified by the strong links between CHVs and communities. The credibility of CHVs is enhanced not only by the fact that they are selected by community members, but also because they When there are stock outs have a reliable supply of health products, and because it undermines our credibility they respond to the felt needs identified by communities. CHV A further positive result of this is that when CHVs seek to promote new healthier behaviors such as latrine use, they If there is no product, act as role models and are more likely to be emulated. there is no program Another example of CHVs taking the lead comes from a SantNet 2 team member commune where they raised funds to build a kitchen and We built our own health vegetable at the local health center, in order to make it center so that we dont more welcoming to patients. An improved environment have to go to the CSB. We have not found a doctor such as this is an important incentive to women to

to work here yet Community member

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Building healthier communities: A review of the Santnet2 Program. delivery at health facilities since accompanying family members have a place to sleep and cook. The interdependence of the different components of the community health system is further illustrated in cases where not all of the components are functional. Qualitative work revealed that CHVs who are not obtaining supplies from the CSPs or CSB are perceived as less credible by the community and receive fewer consultations. It also revealed that the performance of CSBs is perceived as far from optimal in many communes, with community members and CHVs complaining of poor and indifferent attitudes, and absenteeism from health centers. This problem has become particularly acute in the wake of the protracted political crisis and the resulting demobilization of public health services. In one Fokontany community members have such a low degree of confidence in the health facility that they have built a new facility to which they hope to recruit a private doctor. While this illustrates the impact of strong community engagement, it is also clear that many communities in Madagascar would not have the resources to do the same; moreover communities should be able to expect better services from the existing public facilities. At the same time there is a strong indication that despite the political crisis, community level actors, often including the CSBs, are working to ensure that the population can access integrated, acceptable health services. A flexible platform for achieving strategic results Although Santnet2 targets a number of specific strategic results in the areas of maternal and child health, the KMS community health system is a flexible platform that can be adapted to address different health problems over time. There have been examples of this over the course of Santnet2 implementation for instance in the introduction of new themes and health topics through radio and other IEC programming, backed up by outreach work conducted by the CHVs. CHVs and CCDS members have also worked together to respond to new health related priorities and challenges as they emerge; and in some regions CHVs have conducted additional tasks to monitor possible outbreaks of schistosomiasis or tuberculosis. CSPs and the health management information system developed under KMS can also be adapted to respond to emerging priorities. The KMs approach is a system wide rather than a vertical programming approach. Community engagement and a focus on women Santnet2 further developed and refined processes to promote community engagement. Building on the community score card approach piloted by the World Bank in 2008, the Social Quality tool was used by several hundred thousand community members, the majority of whom were women, to define priorities and to provide feedback to CHVs, CSBs and to the program in general. This increased ownership, and the emphasis on community members as stakeholders and rights bearers, has enabled an important shift in accountability, and has led to real changes at community level, perhaps the most visible of which are the increasing numbers of communities adopting improved sanitation and hygiene practices, and the willingness of many communities to participate in building huts for the CHVs to work from. The emphasis on community engagement has helped to shine a light on aspects of the community health system that are not working effectively. Qualitative work revealed that communities may perceive challenges such as low uptake of community insurance, or dysfunctional CSBs, as insurmountable. This is particularly visible in the case of CSBs since local authorities (Fokontany chairs or Communal mayors) have no official authority with respect to health care professionals. This suggests that more work to be done to support communities and 22

Building healthier communities: A review of the Santnet2 Program. their leaders to use the insights from their community based assessment work to effect changes on the one hand, and to use these insights to demand improvements from authorities further up the administrative chain if necessary. Nonetheless it is important to recognize that such changes are unlikely to materialize until Madagascar returns to political stability. The changes initiated by Santnet2 in terms of local ownership and decentralization require stronger support at the policy level if they are to become sustainable. Ensuring quality of services provided by CHVs As a program, Santnet2 does not have an influence on the We need more support and supervision visits quality of service provision within facilities; however, the they help make sure that program model did place a significant emphasis on ensuring we dont fall asleep in the quality of services provided by the CHVs. This was done our work in a range of ways: provision of regular training and CHV supervision; development of standards and job aids; through monitoring of performance (complied through an information management system). Santnet2 subcontracted NGOs and technical advisors to provide closer support to the CHVs and CCDS in this area. CHVs themselves have worked to improve the quality of their services, for instance by agreeing on set timetables which enable community members to know when they are available. Evaluations of quality of information and prescription, whether conducted by CHVs or health facilities, suggest levels of compliance with service delivery standards are under 60% (Institut National de la Statistique Ministre de l'conomie et de l'Industrie and ICF Macro, 2010), and considerable improvements are needed in this area.

In addition 2011 USAID commissioned survey to access to CHV compliance with service delivery standards found that only 55,7% of CHV where complied in describing pills advantages and disadvantages and instructions on its correct use. The proportion was 53% for the DMPA ( injectables ). Maintaining quality has been essential to ensuring other aspects of the system work, in particular the engagement with CSBs and communities, since credibility of the CHVs work is of the utmost importance in both cases. CHVs have stated that monitoring and supervision is an important input to their work.

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Building healthier communities: A review of the Santnet2 Program.

Figure 7 : A CHV waits in her health hut. The timetable posted on the wall outside sho ws the times that she is available at the hut. However, CHVs are also happy to attend emergencies outside of hours

Motivation of CHVs Internationally-developed frameworks designed to evaluate community health care worker programs emphasize the vital role played by motivation in the performance of CHVs. The qualitative investigation carried out for this review confirmed that this is the case for CHVs in Madagascar. There is no centrally-established standard for motivating CHVs in the Santnet2 program. They are volunteers, and receive no stipends apart from on occasions where they travel for training however even in these cases the stipends are very low and strictly only sufficient to cover their board and lodge during the training. Many CHVs state that they are de facto motivated to work for their communities, and that this is why they agreed to take on the CHV role. However, the time that they spend on the role is often considerable, particularly when they accompany patients to the CSBs, or when they are asked to submit multiple reports to the different projects supporting them. Consequently many admit that they would welcome a greater level of support or recognition.

We were chosen by the community and it is a pleasure to do this work Being a CHV enabled me to get skills We spend a lot of time doing this job and the community does nothing to motivate us CHV It is our role to motivate them. We dont do much but we sometimes club together to provide meals for the CHVs, for example during awareness-raising. We put some money together to take the CHVs for a trip to the sea as they had never seen it. We also set up a solidarity fund. But we need to motivate them more perhaps by helping them in their fields. Perhaps more technical support for the CHVs who are struggling would help CCDS members We dont have a system but if the CHV helps us well always give her something Community member

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Building healthier communities: A review of the Santnet2 Program.

Some but by no means all communities have looked for ways to show their recognition to CHVs. Examples that have been provided include helping CHVs with their smallholdings, providing meals or even trips or solidarity funds for CHVs. An effective reporting system CHVs, as well as other local actors such as the CCDS members and the CSP and local health care providers, generally agree that periodic reporting of activities such as community case management and referrals is useful. It enables monitoring of progress and of cases of illness, and can help identify priorities for future action on health. It was also described as being particularly valuable for monitoring stocks of medicines and supplies, thereby enabling the CSPs to resupply and to order new stocks in good time.

The reports are proof we are doing something If we see numbers dropping [in the reports] it encourages us to try harder next month There is lots of paperwork, many complicated reports. They allow measurement of our work but there are too many. We dont need all of these reports to know these things. CHVs Reporting is not a big burden but the NGOs do not help they ask for too much. There is no coordination CCDS member Reports are useful. The number of cases of illness can be seen and we can monitor the stock of drugs. But reports only look at numbers we also need to go to the communities to see what is happening CSB doctor

At the same time, for many the volume and detail of reports is burdensome, and takes up a large amount of time which, added to the time the CHVs already spend on providing services and doing community outreach, is a highly demotivating factor. Moreover, because a number of CHVs are also acting as CHVs under other programs, they find themselves filling multiple copies of similar but not identical reports. The result is that they spend additional time to provide data that may not be valid (as it leads to double counting); and some CHVs resolve this by submitting reports alternately to their different NGO partners. The perceptions related to reports reveal a potentially bigger issue in the way community health systems are implemented and managed in Madagascar. There are a number of programs and organizations involved in this work, and they are unevenly distributed throughout the country. There may be a degree of rationale for this as different agencies have different priorities, and health problems themselves are not evenly distributed. However, the perception from communities is that either they are being neglected, or that they are being overburdened with similar but not identical processes. Stronger stewardship from the Ministry of Health will be a crucial determinant in resolving this situation.

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Building healthier communities: A review of the Santnet2 Program.

LESSONS LEARNED
The Santnet2 program built on learning from many years of implementation of community health programs in Madagascar. It faced particular challenges however, as it developed a more comprehensive model, implemented at a larger scale. Santnet2 was also implemented as Madagascar entered a serious political and economic crisis, which has placed a heavy toll particularly on the poorest, and which has further weakened an already under-resourced public health system. It is hoped that a new political settlement in 2013 will enable Madagascar to begin emerging from this crisis. It is also hoped that the experience of the Santnet2 program model, as described in previous chapters, as well as the insights described in this chapter, can inform efforts to further strengthen the health system and more effectively respond to the needs of the Malagasy population. A number of specific lessons should be considered in adapting and further developing the KMs model: CHVs may be able to take on further roles Many CHVs over 3,600 have been trained to provide both maternal and child health services. Others, either through Santnet2 or other programs, have added additional activities or services to their mandates and have achieved this successfully. There are, therefore, strong indications that CHVs may be able to take on more in their roles. CHVs, community members and local CCDS members had a number of suggestions for additional activities and services that CHVs might take on, as the table below shows.
Services that community members, CHVs and CCDS members suggested CHVs could provide Services for men, young people, and children over five Working in Fokontany that are close to CSBs focusing particularly on awareness raising rather than case management Other forms of contraception (e.g. IUDs and implants) Vaccinations Adolescent reproductive health First aid Additional skills in how to manage or stabilize medical emergencies in advance of evacuation/referral Treatment for other illnesses (e.g. high blood pressure) Delivering babies (midwifery)

Some of the services suggested in the table, such as first aid or adolescent reproductive health reflect additional health needs that are not being addressed but that might be suitable to the skills and role of a CHV they are auxiliary services that do not necessarily need to be performed in a health facility. However, other suggestions such as different forms of contraception and midwifery appear to stem more from the weakness of current CSB provision. Any addition to the case-mix of CHVs should be carefully considered within the context of the entire service provision environment, since working through CHVs may not always be the optimal solution, particularly if the role is better suited to a health care professional. Additions should also be piloted with a smaller number of CHVs before scale up, paying particular

26

Building healthier communities: A review of the Santnet2 Program. attention to the additional workload (current estimated workload of a CHV is 3 half days a week) and the possible requirement of introducing payments. The existence of multiple funding programs and sources of support have enabled community health programming to reach an unprecedented scale. However, arrangements can be made more efficient and less burdensome on local communities. As noted in the previous section, one of the strengths of the KMs model is that it is a platform which can be used for different specific program goals, rather than a vertical service provision model. As a result, programs with different technical focuses, such as malaria, immunization, maternal health, water and sanitation, adolescent reproductive health, and others, have been delivered through the system. However, because many CHVs end up being tasked with delivering on multiple programs, and because each program has its own supervision, monitoring and reporting mechanisms, the additional burden on CHVs is not just limited to the extra service provision which in itself is manageable. A further negative impact of this is that monitoring data We want sustainability you NGOs just come and becomes less reliable since CHVs have varied strategies for go. dealing with the reporting burden such as split reporting or double reporting. CHV As CHVs become a more defined and recognized part of the The constant change in the organizations we community health system, programs and partner work with is a problem organizations should seek to streamline and harmonize for us. their support through a common platform so as to enable CCDS member CHVs to focus on their community roles. This means harmonizing training, supervision and monitoring. It will mean that attribution of impacts should be shared between different actors, so that monitoring focuses on collective rather than individual program results. Once again, strong stewardship from the Ministry of Health will be critical to ensuring coordination, harmonization, and standardization of interventions, as well as to avoid duplication of effort and overburdening community actors. An effective community health system relies on reliable, good quality service provision at the health facility level. Although the CHV model is in part designed to relieve the burden on under-resourced, busy health facilities, it is not designed to replace these. That community members have come to rely so heavily on CHVs is not just testament to their work, but it also indicates that much provision at CSB level is far from optimal. Absenteeism, poor service and informal payments have all been mentioned as problems faced when presenting for services at the CSB. It is clear that additional investment is needed to strengthen and incentivize performance in these facilities. It is also important to maintain support to other components of the system. Planning tools have proved valuable for CCDS members, and focused support is likely to be needed for community supply point managers so that they can maintain their service. It has emerged that CSP managers in some locations lacked the funds to buy initial stocks; program support organizations should identify solutions to such difficulties. Particular attention should be paid to communes covering large geographical areas, such as in the southern Androy region which is also characterized by the highest incidence of poverty. 27

Building healthier communities: A review of the Santnet2 Program. Communities show a high level of resourcefulness in organizing to respond to specific health related problems they face. There are many examples of community organizing to deal with a range of issues such as ensuring community members have the financial solidarity they need to deal with medical emergencies, strengthening evacuation systems, building health insurance mutual funds, and motivating CHVs. Many of these initiatives came from communities themselves, underlining the important principle that community mobilization should not be directed or imposed from the top down. Basic documentation of some of these results, or even the organization of exchanges or tours between CCDS members or CHVs in neighbouring communes, may enable some crossfertilization of ideas and may inspire more communities to act creatively. Santnet2 has enabled communities to collect and understand data and to appraise the services they receive. Further support may enable them to use this information as a basis for demanding accountability. The Social Quality tool is one of the most important innovations in the Santnet2 information system. Using a rights-based framework it encourages communities to take ownership of the health system, to report on the areas which need strengthening, and to resolve problems where possible. At present there is limited evidence of how communities have used the information collected using the Social Quality tool, or of whether they have also been enabled to engage with other relevant information such as Quality Index findings for their location, or statistics on changes in the health situation of their community. Taking community ownership a step further would involve finding ways of sharing this information in practical, meaningful ways, so that community engagement goes beyond scoring of services towards action. _____________________

Figure 8: Mothers wait outside the community health hut in their village to have their young children weighed by the community health volunteer. Regular weighing of infants and children, often conducted alongside the provision of nutritional support and advice. 28

Building healthier communities: A review of the Santnet2 Program.

WORKS CITED
Cakir V. Personal communication. - 2013. Castle S. Santnet2: Training and Supporting Community Health Workers in Challenging Conditions in Madagascar [Report]. - [s.l.] : RTI International/SantNet 2, 2011. Institut National de la Statistique Ministre de l'conomie et de l'Industrie and ICF Macro Madagascar DHS, 2008-2009 [Report]. - Calverton, Maryland : ICF Macro, 2010. Institut National des Statistiques/Direction des Statistiques des Permanent/Periodic Household Survey [Report]. - Antananarivo : [s.n.], 2010. Mnages

Kinfu Dal Poz, Mercer, Evans The health worker shortage in Africa: are enough physicians and nurses being trained? [Journal] // Bulletin of the World Health Organization. - [s.l.] : World Health Organization, 2008. - Vol. 87. The World Bank World Development Indicators Madagascar [Online]. - 2013. - April 2013. http://data.worldbank.org/country/madagascar#cp_wdi. WHO Global Database on Child Growth and Malnutrition [Online]. - 2013. - April 2012. http://www.who.int/nutgrowthdb/database/countries/mdg/en/.

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Building healthier communities: A review of the Santnet2 Program.

ANNEX

The NGO field technicians capacities (FT) have improved steadily


FTs competency is one of the key factors to achieving better results because they support community actors and act as an interface between the community and the Project. Most of the FTs are male (100 out of 146), and 83 of all FTs are married. Most of them are aged 31 to 40.

FT PROFILE (N = 146)

Male Female Education Single In union

68% 32%
High school

43% 53% 35 years

FTs distribution by age

Median age

In terms of education, most FTs have completed a level between high school and five years of university studies (masters level).

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Building healthier communities: A review of the Santnet2 Program.

FTs level of education

In general, the FTs demonstrate good performance in supporting communities to implement activities. Their capacity is directly reflected in the performance of communes that they support, working to improve community health. The communes satisfactory performance was maintained during the reporting period overall: 737 communes achieved satisfactory performance in FY 2013s first semester compared to 724 in FY 2012s last semester. For 135 FTs, the performance level is at about 92%. 11 FTs out of the 146 have an average performance of 60%, due to the remoteness of their sites and their challenges in terms of motivating their communities. Performance of the 800 KM salama communes, with the support of the 146 FTs

Source: Review and CCDS self-assessment reports, April to March 2013.

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Building healthier communities: A review of the Santnet2 Program.

FTs performance is also measured in terms of completion of planned activities, namely supervision and collection of community health volunteers monthly activities reports: 40 FTs completed more than 90% of planned activities. 31 FTs completed between 75% and 90% of planned activities. 42 FTs completed between 50% and 75% of planned activities. 33 FTs completed less than 50% of planned activities. Since project inception, FTs have been trained an average of every six months, as shown in the following table: FT training topics and objectives

Training topics KM salama approach

Training objectives Introduce FTs to the approach

Date July 2009May 2010

Management system for Give FTs the skills needed to July 2009May 2010 data compliance support community health volunteers in using various management tools Supervision strategies Social Quality approach Build the FTs capacity to carry out April 2011 supervision Build the FTs capacity to promote November 2011 responsibility-taking at the local level in identifying and addressing health needs Build FTs competency to OctoberNovember o Train CCDSs on the Wash 2011 program; o Monitor and support CCDSs in implementing Wash activities

Wash

Organizing monthly Increase the community health April 2012 field visits to coach and volunteers reporting rate supervise community health volunteers, information pipeline, monitoring and reporting Community health Strengthen the monitoring of data November 2012 volunteers quality for community-based management tools services

32