CCM Policy Change and Scale-Up Lessons from Nicaragua Health Policy and Planning 2010

1. CCM Policy Change and Scale-Up Lessons from NicaraguaHealth Policy and Planning 2010 Asha George (UNICEF), Elaine P. Menotti (USAID), Dixmer Rivera & David R. Marsh (Save the Children)

2. Outline • Literature Review • Scale up and innovation • Intervention complexity • Policy landscape • opportunities, bottlenecks, actors • Policy and implementation processes • Engaging policy dialogue • Introducing pilots • Scaling up implementation • Lessons Learned

3. Scale Up Literature • No single approach to delivering interventions at scale • Gilson & Schneider 2010 • Political commitment: needs to be actively created • Rational planning important, but also flexibility and strategic flair • Technology transfer & information dissemination is an interactive process: learning, adaptation • Changing organisational norms, values, incentives, etc • Time for adaptation of innovation and health systems • Mangham & Hanson 2010 • Quality & Equity key concerns in scaling up

4. Innovation & Scale-Up Literature Greenhalgh et. al. 2004 • Innovation attributes • Adoption process • Assimilation • Diffusion & dissemination • System antecedents • System readiness • Outer context • Implementation & routinisation • Linkages Simmons & Shiffman 2007 • Innovation • Resource organisation • User organisation • Transfer strategy • Context ExpandNet Peter Fajans RHR/ WHO

5. Scale Up: Key Categories • Problem and innovation/ intervention • Policy landscape: • opportunities, bottlenecks, actors • Policy and implementation processes: • Engaging policy dialogue • Introducing pilots • Scaling up implementation

6. Intervention Complexity: Why is it important? (Gericke et al. 2005) • Non-financial resources are required to implement and sustain an intervention. • Capacity gaps can be addressed • by increasing technical capacity • or reducing complexity • New technology • New guidelines • New cadres

7. Intervention Complexity:What is it? • Nature of the intervention • Product design: Stability, standardisation, safety, storage and transportability • Delivery characteristics • Distribution: Public or private • Service: Scheduled, outreach, outpatient • Inputs: Human resources, communication & transport, facility back up • Government capacity requirements • Legislative and regulatory capacity • Management systems • Capacity for collaboration • Usage characteristics • Ease of usage, pre-existing demand, black markets

8. Intervention Complexity:How does it apply to CCM? • Nature of the intervention • Standardised and safe • but human service: involves curative discretion, possible error • Delivery characteristics • Outpatient & unpredictable • Significant inputs: supplies, supervision, referral • Public and private distribution possible • Government capacity requirements • Legislative and regulatory capacity: authority to treat • Management systems & capacity for collaboration • Usage characteristics • Requires patient education • CHWs and communities least empowered • Risk of black markets vs. discourse of lack of access

9. Scale Up: Key Categories • Problem and innovation/ intervention • Policy landscape: • opportunities, bottlenecks, actors • Policy and implementation processes: • Engaging policy dialogue • Introducing pilots • Scaling up implementation

10. Policy Landscape:Contextual Opportunities • Role of MoH in Health Care Provision • Article 5 General Law on Health • National Health Plan 2004-2015 • History of community participation • Brigadistas • Enabling child health strategies • IMCI & PROCOSAN from 2003 onwards • Decentralisation of MoH to SILAIS (Departments) • Catalytic actors • Save the Children & internal champions SILAIS, MOH

11. Policy Landscape:Implementation Challenges • Brigadistas • Policy restricts antibiotic prescription • Skepticism about delegating curative tasks • Turnover • Concerns from health staff • Workload, competition, quality of care • PROCOSAN: Sustained financing, service delivery constraints, no vertical mandate within MOH, dependence on NGOs • Changes in political administration • Despite being Nicaragua significant uncertainty

12. Outline • Literature Review • Scale up and innovation • Intervention complexity • Policy landscape: • opportunities, bottlenecks, actors • Policy and implementation processes: • Engaging policy dialogue • Introducing pilots • Scaling up implementation • Lessons Learned

13. Starting Policy Dialogue • Catalysing engagement • Technical and financial inputs combined with local knowledge & strategic insight • Field visits, face to face meetings among broad range of stakeholders, participatory situation analysis identifying benefits, challenges, concerns They shouldn’t dismiss something that they don’t even know. This requires very high levels of advocacy. It is important to influence from the top down and at the same time from the bottom up. (Interview MOH)

14. Starting Policy Dialogue • Quelling opposition • Framing rationale (equity, targeted, no alternative) • Program precedence (injectables, treatment) • Compromise vs. full conversion The population doesn’t have to go all of the way to the health post and because of that, their costs are reduced and that is favorable to the new government’s politics—the community members are served right there in their own community. (Interview SILAIS).

15. Introducing Pilots • Monitoring and communicating results • Collecting, using and performing data: trust Initially we thought that the brigadistas would misuse the medicines, but they have handled the medicines well, as per the results we’ve gotten. (Interview Health Centre) [Barriers] can be overcome with results and evaluations as we have seen that there are no [instances] of over diagnosis or over medication... The fact that we had analysis and results from CCM - we found that 90% of treatments provided were appropriate. (Interview SILAIS)

16. Introducing Pilots • Adaptation through participatory consultation • Acknowledges and builds on existing expertise • Ensures relevance • Fosters buy-in We have the satisfaction of being the pioneers of this strategy and the clarity that this is a MOH strategy, not that of an NGO. (Interview Health Centre) The special part of this project was that it was able to be ‘Nicaraguan’ rather than a canned project. (Interview MOH).

17. Introducing Pilots • Nurturing health staff cohesion • Participatory forums to air concerns • Framing strategy in their interests • improve coverage/ fulfil targets • ensure more accountability from brigadistas • enlist community participation in promotion activities • Training to improve supervision & coordination In the beginning I thought that it would be more work - but rather it was the opposite. (Interview Health Post). Every beginning is threatening. Health personnel erected barriers, had difficulties and negative attitudes, but eventually they realized the benefits of CCM. (Interview Health Centre)

18. Scaling Up Implementation • Joint problem solving • Changes in drug regimens • Expecting turnover: training more people • Changes in administration MOH has many limitations and this type of coordination with different organizations has made it possible to support communities. We have learned to negotiate, create solutions and resolve problems. (Interview Health Centre)

19. Scaling Up Implementation • Fostering sustainability and learning • Differing responses regarding sustainability • Concurring responses regarding learning [We had the opportunity to] work with other organizations in a technical assistance model, with the process systematically documented so that it can be applied in areas where XXX is not working. …Even though it was a slow process of development, we were able to take the steps to develop the methodology. They were little steps. Life gives us big tasks, but we learnt that we can’t do it alone, that we need to form alliances, use evidence to demonstrate impact, have political support to convince the highest levels of the MOH. (Interview MOH).

20. Outline • Literature Review • Scale up and innovation • Intervention complexity • Policy landscape: • opportunities, bottlenecks, actors • Policy and implementation processes: • Engaging policy dialogue • Introducing pilots • Scaling up implementation • Lessons Learned

21. Lessons Learnt: Context specific decision making • Persistence despite adversity • Negotiating compromises & local adaptation without losing strategic principles • Operational planning while still flexible • Balancing collaboration: • local vs. central • national vs. international

22. Last Reflection When I analyze everything, I realize that this project has progressed under the hand of God. It could have gotten derailed, stuck or paralysed, but this was all overcome….It has been a process of mobilizing incredible levels of commitment, which is a very stressful and delicate effort. Any mistake could have been fatal, but we kept at it, fixing things as we went along. (Interview Save the Children staff)