Community Health Approaches in Conflict and Post-Conflict Countries

1. Haiti, South Sudan and the Democratic Republic of Congo Community Health Approaches in Conflict and Post-Conflict Countries Charles Franzén – May 26, 2008

2. What is Community Health? “Communities are an essential determinant of health and the indispensable ingredient for effective public health practice.”

3. “Ensuring that badly needed resources and services reach their ultimate destination and fulfill their ultimate purpose of improving health at the community level.” --Global Health Council, Preliminary Program (2008)

4. “Reaching people beyond the end of the road.” --Dr. Uche Amazigo, Director—African Program for Onchocerciasis Control

5. IMA World Health Major Program Areas 1) HIV Care & Treatment Services (ART) • AIDSRelief Project ($335m, 5-year project) – no fixed amount for IMA and/or other consortium members 2) HIV Care & Support Services (HBC & palliative care) • Tutunzane HBC Project in Tanzania – ($100k-200k p.a.) • Global Fund HIV/AIDS DRCongo in 25 Health Zones 3) Maternal, Newborn and Child Health Services • ACCESS Project in Tanzania, Uganda, Kenya, etc. TBD

6. Major Program Areas 4) Health Systems Development & Strengthening • SANRU III in DRC (ended 2006) ($27M, 5-yr project) • AXxes Project in DRC ($40M 3-year project) • South Sudan Umbrella Program to Provide Basic Package of Health Services (MDTF/World Bank) • PMURR project (3 grants supporting 23 HZs) in DRC – ($14M) • SANRU Program & SANRU NGO (planned)

7. Major Program Areas 5) Malaria Treatment and Control • Global Fund - DRC to 16 Health Zones • Malaria Community Programs • CSSC MCP/PMI Project in Tanzania -- $1.5 million over 5 years • UPMB MCP/PMI Proposal Submission in Uganda (under review) • IMA World Health provides Technical Assistance

8. Major Program Areas 6) Neglected Disease Treatment & Control (NDTC) • RTI/USAID funded Haiti NTD Integration Program – LF & STH -- $1 million+ annually for 3-5 years • New USAID/World Bank LF-Morbidity Management funding for India & Togo • LF project in Haiti (University of Notre Dame) • National Onchocerciasis Control Programs in Tanzania and DRC – moving into long-term sustainability phase • Nicaragua Deworming (on-going) • Burkitts Lymphoma (on-going in Tanzania) • Long-Term Programs Completed: • The Kilosa Rotary Project (water & sanitation, Oncho, & ITN distribution) • LF (WB/Gates)- NGO partnerships in India, Burkina, Nigeria, and MOH partnerships in Ghana and Tanzania; Included West Africa LF Morbidity Management (hydrocele surgeries)

9. Major Program Areas 7) Procurement and Logistics Management • IMA Medicine Box • Diflucan Partnership Program (coordinators in Tanzania, Zambia (thru CHAZ), Haiti (thru Association of Christian Health Institutions of Haiti (AICSH) • Pharmaceutical Supply for USAID PEPFAR Program in Haiti in partnership with AICSH • Liberia Revolving Drug Fund Supply Management System

10. Major Program Areas 8) Pharmaceutical Donations Programs • Pfizer Diflucan Partnership Program (Tanzania, Zambia, Haiti, and other countries) • The Medicine Box • J & J donations • GSK donations • Merck donations • Abbott donations • Axios International (DRC) • Becton-Dickinson • Boehringer Ingelheim • Bristol-Myers Squibb

11. Major Program Areas 9) Capacity Building of FBO Networks • Human Resource Capacity Development (Capacity Project/IntraHealth-USAID) • Mapping – with Global Mapping International (GMI) • Information Systems development • FBO health network advocacy • FBO Co-management of health systems • Improved planning/coordination with MoH

12. IMA World Health Program Implementation Mechanisms • Provides Technical Assistance to partners and FBOs through • IMA staff e.g. AIDSRelief/Tanzania, South Sudan, ACCESS, Capacity, etc. • Consultants, e.g. SANRU, AXxes, AIDSRelief Year 1 and part of Year 2 in Zambia, Kenya etc. • Staff of IMA member agencies e.g. In DRC and phase I LF in Haiti • Staff hired through CHAs, e.g. Zambia DPP, Haiti PEPFAR, AIDSRelief Year 1 in Kenya (CHAK) and Uganda (UPMB) • Financial Reporting to the donor by HQ staff and direct implementation and oversight by Grantees e.g. LF • Direct procurement by HQ staff and in-country logistics management by local partners, CHAs, Technical Staff

13. Republic of Haiti

14. IMAWH Community Health Approach in Haiti • Work in close collaboration with the Ministry of Health and the Christian Health Association of Haiti (AICSH) • Very disease & disease-elimination focused • Work in Lymphatic Filariasis for past 10 years • In the past year, consortium prime on RTI/USAID funded NTD Integration Program focusing on LF and soil-transmitted helminths

15. 15 years of Community-Directed Treatment (ComDT) in Tanzania provides many lessons for community health interventions in Haiti • Communities ‘own’ the program as they ‘own’ the diseases themselves • Treatment and record-keeping done in community by community members • Follow up, supervision and monitoring all community-directed • Close linkages with AICSH and the Ministry of Health

16. Haiti – Challenges and Limitations • Integration of two Ministry of Health ‘kingdoms’ (LF and STH) a major challenge • eg. Office Space, equipment, staff, vehicles, per diems • Integration and agreement of two national disease control programs using similar strategies • Esp. challenging in the Community Health perspective • ComDT vs. School Health drug delivery

17. Managing partner/collaborator expectations • Purchase of DEC as this is not a targeted donation from a major pharmaceutical company • Scale-up to country wide coverage in three years – is this really possible with high quality interventions and high coverage among the eligible populations? • How to balance scale-up with true Community Health approach? • General insecurity and continuing civil unrest in PoP and along the major routes upcountry

18. South Sudan

20. IMAWH Community Health Approach in South Sudan • One of the vastly underserved populations on the planet (37 doctors for 10 million people!) • How are State, County, Hospital and facility health delivery mechanisms going to reach the people in need in rural areas? • Focus on BPHS program creating community health outreach through county/health zone strengthening • Reestablish community health workers

21. Sub-contract and monitor health NGOs and INGOs in Jonglei and Upper Nile states, strengthening through capacity-building into county health managers • Deploy diaspora Sudanese doctors to facilities to reestablish community linkages • Reestablishing community health outreach to facility catchment areas • Emphasis on training and building capacity through training schools and programs • Community members selected for basic training in health and hygiene

22. Emphasis on women’s health, maternal and child care issues including addressing conflict and post-conflict gender-based abuses • Important linkages with local Sudanese health service providers • Liaison with transitioning OFDA/USAID opportunities and additional MDTF programs • In the two states, work through our faith-based partnership including World Relief, World Vision, SIM, SIC, PRDA, C&D, CMA, ADRA and the vast network of the newly formed Christian Health Association of Sudan (CHAS)

23. South Sudan – Challenges & Limitations • Pre-post-conflict complexities, full implementation of the Comprehensive Peace Agreement (CPA) • Insecurity and armed clashes a reality to date • Extremely weak central government with little or no human resources capacity outside the Ministry of Health • Community Health less a priority than basic survival • Many health cadres not refresher-trained in 20+ years • No experience of decentralization and decision-making at health zone/county administrative units • Managing expectations of partners/collaborators esp. over use of sub-grants • Very poor financial and accounting capacity across the board

24. As typical in other similar situations, extremely high cost of materiel and salaries • eg. Some Clinical Officers receiving $3,000 p.m. • Conflict in Unity State over boundary commission rulings on ownership of disputed oil-bearing lands – this also extends into Jonglei and other potential oil-bearing states • Millions of Sudanese are either refugees in other countries or IDPs in the North or scattered areas of the South • Flood season (April-November) rendering access poor – Supply Chain Management requires pre-positioning to be workable in every case

25. The Democratic Republic of Congo

26. IMAWH Community Health Approach in the DRC • Communitaire, Health Zone and ‘Appui Global’ systems very well developed from SANRU I, II & III and are being built on in the AXxes Project • Community Health linkages through the community health worker relay system and centrally placed delivery mechanisms • Emphasis on vaccination and mother and child health throughout the program

27. Conflict Resolution including addressing gender-based violence and its aftermath • Protestant, Catholic and MoH linkages within the Health Zone system – each with an equal role to play bringing their added value to all areas where they are strong • In AXxes, proven Community Health experiences of IMA World Health, World Vision and CRS throughout the DRC creates a synergy of high expectation and consequent high achievement

28. DRC – Challenges and Limitations • Severe limitations in post-conflict and pre-post-conflict areas • Humanitarianism vs. Community Health • High expectations from donors after previously successful effort – ‘Peter Principle’ in some health zones • Extremely weak central government support – advantage (humanitarian work) vs. disadvantage (development work) • Capacity-Building in Human Resources Management and Continuous Training/In-Service Training • ‘Reverse Cornucopia’ – trying to take on too much under very trying circumstances • Management of sub-grantees/partners and universal health zone administration standards and principles

29. Advantages to Working with Faith-Centered Health Service Delivery Networks for Community Health • Effective Peace and Reconciliation efforts are often faith-based and faith-centered • Members of faith-based indigenous networks provide 30-60% of health care in developing nations • Often the most important partner with the Ministry of Health in health care service delivery • In some countries, faith-centered organizations are known as the founders of Community Health programs • Faith-based training institutions likewise are responsible for training a majority of health workers • Much closer to local communities and local authority structures – act as ‘voice’ of the very poor • In DRC, Haiti and South Sudan, IMA World Health’s work could not be done without true partnership at the local level with the faith community