Mesoamerican Health Initiative December Introduction 2

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1 CONTENTS Introduction 2 1 Integration And Other Key Concepts 4 2 Strengthening Horizontal Elements Capacity Building Health Information Systems Policy & Advocacy Community Participation 18 3 Integrated Delivery of Care Immunization Nutrition Reproductive, Maternal & Neonatal Health (RMNH) Vector-Borne Diseases: Malaria and Dengue 32 4 Conclusion 37 Appendix 1 Background on the Mesoamerican Health Initiative 37 References 38 1

2 Introduction The Mesoamerican Health Initiative brings together Mexico s southern states and the countries of Central America to share the benefits of good health among all people, especially mothers and children. This five-year Initiative is dedicated to significantly reducing health inequities by decreasing preventable illnesses in the following four areas: Immunization Currently, one in four Mesoamerican children fails to complete their basic vaccinations, increasing the risk of diphtheria, tetanus, pertussis, tuberculosis, polio, and measles. There are gaps between reported national vaccine coverage rates and those in the most vulnerable populations in the region. Nutrition Every year some 600,000 Mesoamerican children under age five suffer from Vitamin A, iron, or zinc deficiency. Many more are malnourished, experiencing poor growth or cognitive underdevelopment. The prevalence of stunting due to malnutrition is two times higher in rural areas, and 50 to 125 percent higher in indigenous populations 1 than in national averages. Reproductive, Maternal and Neonatal Health (RMNH) One in five pregnant women receives no prenatal care or gives birth without a skilled birth attendant. Maternal and neonatal mortality rates are noticeably higher in rural and marginalized urban areas where health infrastructure is weak and where there is a shortage of trained obstetric personnel. Vector-Borne Diseases (Malaria and Dengue) Some 50,000 Mesoamericans contract malaria and 70,000 contract dengue annually, while another 10 million are at risk for these diseases. People living in rural, remote and poorer areas are more likely to suffer the effects of these vector-borne diseases. Preventable illnesses in these four health areas disproportionately affect the region s poor, indigenous, and remote populations. The failure to meet the fundamental human needs of autonomy, empowerment, and human freedom is a potent cause of ill-health, 2 is true for disenfranchised people of Mesoamerica. Systemic factors, including low social status, poverty, and difficulty accessing health services further exacerbate the poor health of vulnerable groups. Within indigenous communities, gender inequities impact women s health status and access to care. Women have lower cash incomes and lower status than men. Women face a greater number of health risks, in part because of their reproductive role. While women have different health needs than men, they have less opportunity to access health resources with such decisions in male hands. Less access to nutrition, education and employment give women less opportunity to enjoy good health. Thus, the Initiative aims supports greater health equity at national levels with interventions targeting vulnerable women of reproductive age and young children. In most cases, women and children who are poor, indigenous, or who reside in rural areas are the priority recipients of the Initiative s attention. Two strategies are central to he Initiative s achieving greater health equity: 1) employing evidence-based interventions in a cost-effective and culturally appropriate manner and 2) executing Initiative activities in a manner that avoids doing harm to existing health systems. Large-scale initiatives can inadvertently damage health systems, rapidly overloading fragile financial, clinical, and information structures beyond their ability to function. The Initiative seeks instead to strengthen health system components upon which disease-specific activities rely. 3 Integration, both at point of service and with targeted health system strengthening, is critical to these strategies success. A Region Plagued by Inequity A historic lack of attention to the poorest populations in Mesoamerica has resulted in worse health outcomes for the region s vulnerable and impoverished communities. Inequitable health outcomes are further 2

3 complicated by social determinants of health including: unequal distribution of power and resources, abject living conditions, and health services confined mainly to urban areas. Together, these factors contribute to systemic and entrenched health disparities. Health equity, or all people s right to just, impartial and fair health care, is among the Initiative s highest values, and must be made explicit across implementation strategies. In the Mesoamerican context, equity entails redressing the skewed distribution of resources that has resulted in poorer health and higher mortality for disenfranchised people. A growing body of evidence demonstrates that health outcomes and health expenditures are far from equal in Mesoamerica. Life expectancy among indigenous populations lags behind national averages by up to 28 years. 4 Indigenous persons are as much as three times more likely to die of preventable causes Equity such as birth-related illnesses and diarrhea. A study conducted in revealed under-five mortality to be over twice as high in the poorest quintile than in the wealthiest quintile of select populations in Latin America and the Caribbean. 6 Standard health indicators like rates of malnutrition, maternal mortality, neonatal mortality, access to immunizations, and rates of vector-borne disease reflect worse health in indigenous, poor, and rural people. These statistics suggest that an infusion of resources and new health service delivery strategies for Mesoamerica s neediest populations is overdue. It is evident why the Initiative must focus on achieving equitable health outcomes. Appropriate integration is one strategy to achieving that end, as integrated service has more chance of ensuring more equitable access across the spectrum of priority conditions than do a series of single-issue programs. 7 Integrated service delivery can potentially reduce costs, prevent has emerged as a policy priority in global health assistance with the growing realization that the aid and health sector reforms only benefit the poor and marginalized sections of the population. duplication of services, and maximize efficiency. In this context, integration implies improved targeting of interventions, greater cost-effectiveness, enhanced community participation, stronger health systems, and more accessible health services. Applied strategically and with adequate resources, integrated efforts can also contribute to greater health equity. It is the purpose of this report to explore how integrated approaches can be utilized to: increase the Initiative s cost-effectiveness expand access to services, and strengthen horizontal areas of the health system upon which disease-specific programs rely. Countries may consider these findings when selecting activities that best fit their national needs and priorities. This report draws extensively on the findings and recommendations of the Initiative s technical workgroups, conducted by the National Institute of Public Health (INSP) in Cuernavaca, Mexico. Their Situational Analyses, Master Plans, and discussion provided a rich resource for this report. Recommendations were also culled from peer-reviewed and respected grey literature. The report s recommendations are not intended to be prescriptive, but, rather, to help stakeholders reach thoughtful decisions about implementation. The report is divided into three sections. SECTION ONE defines key words and concepts. SECTION TWO proposes strategies for addressing horizontal needs in the following areas: human capacity, health information systems, policy and advocacy, and community participation. SECTION THREE summarizes strategies for the joint delivery of vertical interventions. 3

4 1 SECTION ONE: Integration And Other Key Concepts In general, integration refers to the combining of previously segregated pieces, parts, peoples or efforts. 8 Integration often refers to the joint delivery of services addressing different health issues at the same time, for example contraceptive counseling and HIV testing. Joint service delivery may be provided by the same staff, at the same health visit, or in the same facility. In the context of global health initiatives, integration can also refer to the tethering of an initiative s efforts to those of a country s existing health system. Integration is also interpreted as occurring over time, with interventions provided systematically over the course of life with the intention of achieving a common goal. This final definition is implicit in the Initiative s approach with improved mother, infant and child health ultimately leading to better regional health, especially for vulnerable populations. Integrated delivery of health services can offer such noteworthy benefits as cost-effectiveness, decreased redundancy, increased efficiency, and synergistic health improvements. It can also present drawbacks, however, such as overtaxing health personnel and diluting the impact of specific services. In order to maximize these benefits and minimize drawbacks, implementation plans must address the unique needs of integrated health programs. Studies show, for example, that integrated services will be most successful if providers have adequate management support systems and if users find services to be easy to navigate and appropriately delivered. 9 The extent to which services across health areas are delivered jointly will depend on each community s (or country s) needs. Rifat Atun expands on this balance, The purpose, nature, speed and extent of integration [are] dependent on the intervention complexity, the health system characteristics and the contextual factors. 10 In this Initiative, where health system characteristics and disease incidence vary by locality, participating countries must think critically about how integration can be most effective. Specific opportunities for integrated delivery of health services are discussed in further detail in Section Three. Merging the efforts of a global health initiative with those of a country s health system is a complex issue that has been discussed in global health circles for many years. There is a recent resurgence of the debate with worldwide increases in disease-specific funding and the realization that many health goals, including the Millennium Development Goals (MDGs), may not be reached without additional efforts at health system strengthening. Despite widespread interest and dispute, there is no uniform definition of integration or its framework in this context. Several definitions of integration are used in this report. Some describe integration only across vertical health programs. Others focus solely on integrating health program activities with health systems strengthening. Each framework has strengths and weaknesses. Ultimately, the report combines components from multiple approaches to develop a unique framework for the Initiative (See Figure 1). The structure of the Initiative has often been described as diagonal, an approach developed by Julio Frenk and Jaime Sepúlveda, because it attends to both disease-specific (vertical) interventions and health system strengthening (horizontal) strategies. Frenk and Sepúlveda describe the approach as a strategy in which we use explicit intervention priorities to drive the required improvements into the health system, dealing with such generic issues as human resource development, financing, facility planning, drug supply, rational prescription, and quality assurance. 11 Diagonal programs span various health issue areas and include multiple levels of the health system. 12 In this sense, diagonal approaches provide diseasespecific results through improved health systems. 13 Sepúlveda and Frenk have cited child health improvement efforts in Mexico as a successful example of diagonal health interventions. 14 Both PEPFAR 15 and The Global Fund to fight AIDS, Tuberculosis and Malaria have adopted this approach for low-income countries. 16 4

5 FIGURE 1: Integration Framework for the Mesoamerican Health Initiative The Mesoamerican Health Initiative includes vertical activities in four health areas: Immunization, Nutrition, RMNH, and Vector-Borne Disease. The Initiative also considers three horizontal components: Human Capacity, Health Information Systems, and Policy and Advocacy, to be strengthened in conjunction with disease-specific activities. Underscored throughout the framework is the need for strengthened community participation, which can be considered both a strategy for implementation as well as a horizontal area. There are other horizontal components including infrastructure and governance, although these subjects are beyond the scope of this report. While regional in implementation, the scale, complexity and scope of this Initiative closely resemble other global health initiatives. It will include state and non-state partners, involve new funding or leveraging of funds, and [be] shaped around particular disease addressed through a strategy, or set of interventions. 17 Initiative activities will impact both vertical and horizontal health areas as outlined in the previous paragraph. Simultaneously, efforts of country health systems will affect these components. Through this framework, Integration is considered in three ways: across vertical health areas between horizontal system components and vertical health areas, and between global health initiatives and existing country systems. By integrating at all these levels, targeted health interventions will lead to improved health outcomes and greater health equity. 2 SECTION TWO: Strengthening Horizontal Elements Health programs are often described as either vertical, disease-specific or horizontal, crosscutting. Despite such distinctions, health programs often include both vertical and horizontal elements because of the inherent interdependence of these two thematic areas. Weaknesses in horizontal areas can destabilize the vertical pillars resting on them, making the achievement of health improvement in diseasespecific programs more difficult to reach. Integrating targeted strengthening of horizontal components into disease-specific strategies strengthens the entire framework, shoring up the foundations of all four vertical programs. 5

6 Figure 2: Initiative Framework with Horizontal Component Highlighted Aligning one program s activities in horizontal areas with broader health systems strengthening is a widely supported approach in global health initiatives. One WHO framework refers to horizontal components as building blocks, or structures that perform essential functions including: developing the health workforce, collecting and analyzing information, supporting good governance, and incorporating target communities in implementation design and execution. 18 Systemic challenges are common to both health systems and programs in developing countries. Challenges include inadequate infrastructure for service delivery, shortages of trained health workers, interruptions in the procurement and supply of products, insufficient health information, and poor governance. 19 Mesoamerican health systems are confronting many of these constraints. Enhanced communication between the Initiative s implementers and national health systems can lead to system-wide improvements and, ultimately, better health. Section Two of this report will specifically address the following horizontal areas: Human Capacity Health Information Systems Policy and Advocacy, and Community Participation These four building-blocks directly support the Initiative s vertical program areas Immunization, Nutrition, RMNH and Vector-Borne Diseases and were analyzed in the Initiative s planning phase. This section of the Report summarizes weaknesses and proposes strategies for improvements in the four horizontal components. Implementation of the Initiative will likely consider needs in additional areas including infrastructure needs, program governance and financing mechanisms. 2.1 Capacity Building Introduction The heart of successful health programs is the people. People deliver services, manage programs, and set policies. Health systems are human systems at their core, designed and perpetuated by people. By building the capacity of the health worker (at multiple levels community, primary, secondary and tertiary levels and multiple roles medical, social, technical, managerial) the entire system will perform more effectively. 20 The initiative, in keeping with a diagonal approach to health improvement, integrates human capacity strategies with health-specific interventions. Sources for this section are various. Master Plans describe the human capacity building needs as they 6

7 pertain to the effective implementation of the recommended effective practices documented in the literature. Throughout the planning phase, initiative work groups have also worked closely with an important partner dedicated to capacity building to support health improvements in the region, the Mesoamerican Institute of Public Health, (IMSP in Spanish), funded by the Carso Health Institute. The IMSP completed a survey for all four working groups aimed at identifying capacity building needs, as well as identifying possible existing resources related to the recommended interventions. Preliminary survey results informed the recommended capacity building strategies of work groups. Common capacity building needs Each of the initiative work groups were tasked with considering the primary capacity building needs necessary for successful implementation of the recommended health interventions. Common problems surfaced with respect to capacity building: The driving force of health system performance is the health worker, strategies to address human resource crisis in the developing world will have a positive effect on all health indices. Inadequate numbers of qualified health workers Lacking cultural competency to effectively reach indigenous populations Limited analytical capacity of labs Inadequate numbers of health workers deployed outside urban areas Weak supervision and management skills and processes Low quality, outdated and/ or not culturally appropriate educational materials Limited on-the-job training programs for all levels of health professionals (community health workers, nurses, physicians, technical staff, and managers) See Table 1 for a summary of each group s specific review of needs related to capacity building. 7

8 Capacity Building Needs Table 1 Capactiy Building Needs Nutrition Immunization RMNH Dengue Malaria Training in childhood linear growth monitoring within nutrition programs. Improve the analytical capacity of local labs to conduct food fortification analysis. Include a systematic recertification process to uphold standards in breastfeeding, counseling and related clinical aspects. Increase numbers of health personnel. Strengthen training in supervision and management. Cold-chain training & supervision. Train community-based workers on community involvement Improve deployment of trained personnel to rural areas. Ensure rural areas have adequate equipment and infrastructure. Improve Supervision and Quality Assurance. Train existing personnel: *All levels of providers *Include task-shifting options *Concentrate on providers in marginalized, resource poor settings *Rigorously monitor and evaluate training. Develop regional guidelines or definition of skilled birth attendance. Update curriculum for contraceptive counseling training. Advocacy to encourage ministries of health to include dengue in strategic plans. Training for a variety of health professionals (physicians and nurses), technical personnel (auxiliary nurses, health promoters, vectorcontrol workers, etc. ) and non-voluntary/voluntary community workers. Inventory of educational materials related to Dengue. Communication training in health promotion. Well-qualified malariologist with extensive experience. Coordination with Central Management Group (CMG) for decision making and leadership. Train community health workers to register and monitor cases. Personnel with managerial skills, epidemiologists, informatics, parasitology and entomology technicians, operative field workers and community promoters. At present, most national malaria programs are understaffed and function with poorly prepared personnel. 8

9 Additional priority areas were surfaced in the Mesoamerican Public Health Institute s survey 21, including: Operations and effective implementation of programs Evaluation Developing and defining policies, norms and responsibilities for human resource roles, processes and procedures Program development Addressing financial barriers. Additional problems often discussed in the literature 22 include: Mismatches between needed health worker skills and available skills Inaccurate or incomplete data about the health workforce which hampers workforce planning and decision making Retention problems, including out-migration of trained providers and shifts between sectors Slow and ineffective recruitment, hiring and deployment processes Weak human resources management systems for the health workforce and lack of supportive human resources policies Poor use of available and financial and material resources The need for adequate training systems cannot be understated and is further aggravated by the lack of managerial capacity of systems that fail to get trained personnel to work in rural areas. RMNH Workgroup Possible solutions for common problems Most of the suggestions for capacity building are large scale recommendations that require additional research and planning before they can be delineated into specific programs or actions. However, there are some recommendations that are specific and feasible with the potential to have a dramatic impact. For example, according to the Health Information Systems report, providing low-cost training on cause-of-death coding for 1-2 individuals per country in the region, would drastically improve data that informs regional health planning. Systemic improvements to capacity building approaches are desperately needed, though small-scale, relatively low-cost solutions may be more readily integrated into the Initiative s strategy. 1. Community Health The need for a community driven approach to health and cultural competency was brought up in various contexts throughout all of the master plans and it was a central theme during the in person strategy session conducted in Cuernavaca among all workgroups on November 13, In order to reach target populations, especially indigenous groups that have not been successfully integrated into the health system, cultural competency is an essential capacity that needs strengthened. In order to design interventions that will effectively reach this population, a more complete understanding of the community needs and perspectives is necessary to inform program design and implementation. Qualitative research can open the flow of communication between health professionals and indigenous communities revealing cultural and social values. This deeper understanding of indigenous people can be applied to health promotion, making new behaviors appealing, addressing fears and overcoming barriers. In particular, a cultural liaison, a respected member of the indigenous community with the interpersonal and language skills, in addition to basic technical knowledge, is an essential role that needs to be strengthened as well as receive greater recognition. Further discussion of Community Participation strategies is included in a later section of this report. 9

10 Community Health Workers, (CHWs) can also serve as critical vehicles for integration. By expanding the profile of the community health worker, CHWs could potentially serve as ambassadors for improved personal health care across all four health areas. Whether choosing to breastfeed, receive important vaccines, take vitamins, or install a bed net; these basic effective practices will not be assumed in the target population without the championship of a socially accepted community health worker. Ministries of health can demonstrate political commitment to health equity by dedicating funding to support this enhanced profile of a community health worker. 2. Stronger evaluation capacity The need for improved epidemiological and evaluation competency was the most widely recognized capacity building need from the onset of this initiative. All of the vertical health areas suffer from lack of reliable disease registries as well as little or no evidence in the region of effective programs. Few programs in the region are evaluated. Likewise many of the case examples of best practices are not sufficiently robust to justify replication and scale up. The Information Systems and Evaluation workgroup recognized the need to improve capacity to maintain solid information systems. Particular areas that were suggested: Strengthening vital statistics by providing regular training opportunities on cause-of-death coding using CIE 10. Improving capacity in epidemiological surveillance and data analysis. For a more in depth description of capacity building needs related to information systems, please the next section of this Report, Health Information Systems. Attending to these two particular areas of capacity building related to information systems could potentially have a significant impact on planning and decision making in the region, allowing a more careful and targeted use of limited resources. More widespread use of rapid surveys and evaluations that focus on organizational learning could also enhance the region s ability to make important modifications to design and implementation of interventions. 3. Improved approach to performance monitoring and supervision A third common theme throughout the groups was the lack of accountability for adhering to already existing norms and guidelines related to program policies. For example the Nutrition workgroup stated in their master plan, The health systems should have mechanisms in place to ensure that regular supervisory visits are made to facilities for monitoring the implementation of interventions. Supervision should comprise problem solving in dialogue with health workers, checking that they are providing good quality services according to national or local norms, and monitoring outputs. It should happen in the workplace with immediate feedback to the health worker to assist in maximizing her/her performance (Nutrition workgroup Master Plan, p. 22). While the workgroups underwent a thorough review of the literature of effective practices of addressing disease and mortality/morbidity in each of the four health pillars, many of the effective practices themselves are widely known and even reflected in policies and procedures. What continues to fail is the supervision and follow-up of personnel to effectively implement these practices. In order for best practices to be successfully implemented, supervision is central, yet many supervisors lack the knowledge, skills, and tools for effective supervision. One of the first steps to improving a supervision system is to complete a review of literature on best practices, pilot test, evaluate and compare results. 4. Improve workforce planning and training Limited data and information about current workforce issues severely limits effective planning in human resources for health. A mature and complete human resource information system equips decision makers with the ability to answer key policy 10

11 and management questions, to ensure a steady supply of trained professionals, to deploy health workers with the right skills to the right positions and locations to meet health care needs; and retain health worker skills and experience. 23 A comprehensive overhaul to human resource for health monitoring and strategy would not be feasible in the scope of this initiative. However, a process that includes assessing training needs and documenting best practices in capacity building would be possible and valuable. Studying the status of existing workforce planning efforts and contributing to improved human resource for health strategies may also be feasible. Both academic and applied needs for human resource for health were identified in the Initiative s planning phase. The IMSP s focus is on academic development, and efforts focus on training and preparation to create an effective health and public health workforce. The IMSP recommends masters and doctorate programs in addition to some continuing education and distance learning programs. Health workgroups were more concerned with ongoing training needs for current health providers and community health workers. One workgroup Master Plan argued, Training should be understood as a continuous integral process. It is necessary to review the actual training processes, based on sporadic courses, to move to a more continuous in-service training through supervisors. 24 Work group members are asking for comprehensive and systematic approaches to addressing workforce deficiencies. Taking a more comprehensive approach would entail investigation and strategy development in three primary areas: developing the workforce, planning the workforce, and supporting the workforce. Planning for workforce needs would include ensuring that the right type and number of health workers are deployed to the right locations, improved recruitment, hiring and deployment strategies, competency-based models to promote workforce realignment, and task shifting. Additional work developing strategies to support the workforce would also serve the initiative well. Strategies for supporting the existing workforce would include tools and initiatives to improve job satisfaction and retention, improving supervision systems, refining licensing, accreditation and quality assurance programs, among others. Strengthening in-service training, professional associations, and continuous education are all activities that fall under supporting the existing workforce. Supporting the Existing Workforce Evaluation of in-service training is critical because while many training modules have been offered in the region, many have not succeeded. Identifying those programs that have been successful and illuminating why would be extremely helpful for the region. Conclusion Building the capacity of the workforce is an essential component of ensuring the success of the initiative. For the long term, however, planning and growing the health workforce will be necessary to respond to the complexity of needs surfaced in the master plans. In summary, suggestions for further strengthening capacity building efforts may be to: Prioritize programs in which the Initiative has reached some consensus including: strengthening community health, evaluation, performance monitoring and supervision, and improving workforce data and planning, Focus initially on addressing the capacity building needs for those technical professionals identified as critical to the Initiative and that are needed in limited numbers (e.g., cause-of-death coders). Expand planning of capacity building efforts to include planning for workforce and supporting workforce in addition to developing workforce academically. 11

12 2.2 Health Information Systems Strong health information systems are needed to produce valid, reliable and timely health information, a fundamental component of public health. 25 For this reason, health information is an essential horizontal component of the Initiative. In the planning phase, the Initiative defined three objectives for monitoring and evaluation (M&E): Demonstrate changes in the health status of target populations; Assess interventions to determine their effectiveness and scale; Emphasize cost-effective approaches. Indicators to measure progress toward the Initiative s objectives depend on strong monitoring systems and country data sources, including registries, surveys, and census information. Indicators for the four health areas draw on population estimates and other data from national census and national surveys to calculate morbidity and mortality rates. Deficiencies in information systems limit accurate implementation and evaluation of interventions. The Initiative depends on country health information systems, which vary widely in design, functionality and capacity. In 2009, the Initiative conducted a comprehensive assessment of health information systems and a regional strategic plan to strengthen these systems was developed. Important differences were identified among countries in the quality and availability of health data. Limited coordination, collaboration and communication were noted among the information systems. The lack of communication between information systems hinders the collection and analysis of data of interest to all countries. This section focuses on important limitations of information systems that directly affect the Initiative s health interventions. Recommendations are given to strengthen national and regional information systems. The Health Plan for Central America and the Dominican Republic ( ) includes a strategy for establishing a regional health information system, and represents an excellent opportunity for collaboration to accomplish this goal. Limitations of Health Information Systems 1. Poor data quality The Initiative s ability to evaluate its impact on population health is severely constrained by the limited quality of data on key indicators. Three critical aspects of data quality are coverage, validity and timeliness. Coverage: Important deficiencies in birth and death registry data are documented across the region. This low coverage affects the quality of other important indicators, such as fertility, neonatal mortality, and infant mortality. Validity: Inaccurate causes of death on death certificates are considered a major problem, especially for maternal deaths. Many deaths are categorized as illdefined and unknown causes. Vaccination coverage estimates have also been found to be unreliable even in countries with strong immunization programs. Household surveys in several southern Mexican states that used immunization cards to confirm vaccination status (unpublished data), suggest lower immunization coverage than the official statistics (40-50% coverage vs. >90%, respectively). Timeliness: Even when data is available, in some cases it is several years old. Such information has limited use for assessing current needs. A more in-depth assessment is recommended to identify the causes for the poor quality of key indicators. Such information could suggest precise actions to improve those indicators. The PRISM framework tools are recommended for the follow-up assessment. 2. Data not available for certain groups (e.g., indigenous people) and or geographic areas (e.g., rural, isolated, localities) To assess differences in health status, and the Initiative s effect on them, data disaggregated by socio-economic and demographic characteristics is 12

13 needed. Estimates of anemia, malnutrition and micronutrient deficiency prevalence are not available for many indigenous groups. Most information systems cannot provide disaggregated information. The reasons are many: Data collection forms may not include questions on income or ethnicity. Respondents may not identify themselves as members of a vulnerable group, because of fear of discrimination. Language or education-level barriers may prevent collection of this information. Some vulnerable groups live in isolated or unsafe areas and are difficult to reach. There is also limited data at state and regional levels, despite the important role of local health providers in delivering health services. With the recent health system decentralization in many developing countries, most service delivery now takes place at the local level. This is where information is needed most. Data for most health indicators is collected through national health surveys. Although these large surveys provide precise estimates at the national level, few have the statistical power (i.e., sample size) to permit data disaggregating at the local level. 26 National estimates obscure significant differences between and within regions. This issue is especially relevant because program interventions will likely target specific areas where target communities reside. 3. Limited comparability of indicators among countries Comparable data allows programs to assess health differences within and among countries, and to demonstrate changes in health status. Access to comparable data would enable policy makers and health program leaders to understand their situation in comparison to neighboring countries. Although several international organizations and initiatives are promoting use of standardized indicators (e.g., PAHO s Basic Indicators, MDGs), in practice, countries use different data collection instruments and procedures. Differences also arise between national estimates and those reported by international organizations. Maternal mortality ratios for Guatemala in 2005, for example, varied from 149 (national reports) to 290 (WHO reports). There are many reasons for such inconsistencies. Countries may use different definitions and/or measurement tools. There are no standardized survey instruments or survey field implementation protocols for the region. Countries and international organizations may also use different estimation methods. 4. Limitations of national surveillance systems Surveillance is an essential component of information systems. Yet surveillance systems are fragmented and disparate in quality and sophistication. Often they are the result of global health initiatives that prioritize data collection for specific issues, in many cases creating parallel surveillance systems that respond to their information needs, although not necessarily the host country s. Several organizations (e.g., COMISCA, PAHO, CDC) are working to strengthen regional surveillance systems. There is only limited cross-border coordination and communication among surveillance systems. This is especially important given high rates of cross-border migration and also the need for rapid response to health emergencies or natural disasters. Collaboration between neighboring countries is essential for early detection of dengue outbreaks and coordinated control. Another important data quality issue is limited regional and national laboratory capability. For some notifiable diseases, most reported cases are not laboratory confirmed. This issue is especially relevant for malaria elimination. In areas with low malaria prevalence it is important to confirm each suspected malaria case, in order to implement control activities. 5. Need for rigorous evaluation of national programs and regional interventions Although myriad programs have been implemented, there is limited evidence of intervention effectiveness. In general, programs are poorly monitored and infrequently evaluated in a rigorous way. Reasons for these deficiencies include: limited resources to conduct evaluation studies and an 13

14 apparent competition for finances between providing services and conducting data collection; and limited human capacity to conduct impact evaluation studies. This problem is compounded by a lack of a culture of evaluation. Even when health program information is collected, it is not analyzed or applied to decision making. 6. Lack of an up-to-date and legal framework for health information systems, especially in the areas of vital registries and disease reporting. With respect to vital statistics, institutional responsibilities for data collection need review and clarification, as do the roles of different agencies in collecting birth and death data, and also the role of the states versus the national government. 27 Frequently, several agencies have overlapping responsibilities for collecting and reporting the same indicators. A lack of standard data collection methods may produce inconsistent statistics for the same country. In most countries the private sector is required to report specific notifiable diseases. In fact, they rarely do so. Recommendations to Strengthen Health Information Systems These recommendations complement national plans for health information systems strengthening recently developed by Mesoamerican countries with the Health Metrics Network (HMN) framework. 1. Improve data quality Conduct an in-depth evaluation of routine health information data sources for key indicators. Use the PRISM methodology 28 to conduct a more detailed assessment of data quality characteristics for key indicators (e.g., validity, reliability, coverage, timeliness and use), necessary for targeted and effective solutions to these data limitations. Identify priority information and communication technology gaps to support the health information systems. Validate official estimates for key coverage and outcome indicators. Rapid surveys are a flexible data collection strategy characterized by simple (and scientific) sampling designs and data collection limited to a few key indicators. Rapid surveys could be used to validate reported vaccine coverage and to provide data disaggregated by target sub-populations. Benefit Incidence Analysis is another mechanism for measuring how a limited public good (such as immunizations) are distributed across groups in society Develop data collection strategies to ensure availability of information about the target populations. The ability to document health status and to evaluate the Initiative s impact on the most vulnerable will require data disaggregated by sociodemographic variables. It is necessary to ensure these variables are collected by routine health information systems and by other data collection for monitoring and evaluation. Data collection should be culturally appropriate. Sample sizes should be large enough to provide estimates for populations of interest with a precision level useful for decision making. 3. Improve the comparability of health indicators in the region by selecting and using standard regional indicators; developing and validating standard definitions, instruments and methodologies; and preparing procedural manuals for data collection and transmission. 4. Coordinate and collaborate with other ongoing initiatives to strengthen information and surveillance systems. These include HMN, PAHO s Vital Statistics Strengthening Initiative; COMISCA s Regional Intervention to Strengthen Health Information Systems in Central America and the Dominican Republic; Central American Network for the Prevention and Control of Emerging and Reemerging Diseases (RECACER) 30 and Canada s Health Information Systems Strengthening Project in Honduras (ACDI). It is recommended that national and international partners use their resources jointly to enhance entire health information systems. 31 This approach is important to avoid further fragmentation and duplication of country information systems. Enhancing the regional reference laboratory network will, for example, im- 14

15 prove the quality of surveillance data and provide information for more accurate diagnosis and treatment of malaria, dengue, and micronutrient deficiencies. Share databases and resources to develop a comprehensive geographic information system. The goal is to develop a regional database with standard indicators at appropriate geographic levels. Mexico has developed an excellent mapping of indigenous communities using geographic information systems with indicators at the local level. Strengthen the legal framework for health information reporting: More effective incentives for legally required reporting and enforcement of penalties for non-compliance are needed. 5. Adequately fund M&E activities: During implementation, data on some indicators will be available from the routine information systems. Additional information will also be needed, including: outcome monitoring (for performance-based funding), pilot studies and impact evaluation studies. In general, it is recommended that 5-10% of the overall budget be allocated to M&E. Conclusion The Initiative represents an opportunity to carefully assess health improvements among target populations. A functioning monitoring and evaluation system can demonstrate whether health objectives are met and reveal what health interventions worked and why. The Initiative s focus on health equity issues provides both an opportunity and an important challenge to collect information from vulnerable and hard-toreach populations. To ensure the sustainability of the Initiative, a specific evaluation should be planned and conducted in alignment with country information systems and other ongoing evaluation efforts. 32 The Health Metric Network recommends strengthening, adapting and utilizing existing systems. 33 The Initiative should explore ways M&E activities can strengthen information systems and evaluation capacity in a structural manner. Systematic involvement of country institutions in monitoring and evaluation will help strengthen information system capacity. Adequate resources should be dedicated to strengthening human and technical capacity in routine data sources and program evaluation rather than building parallel M&E systems, which may damage existing country systems. These recommendations support the tenets of the Paris Declaration on Aid Effectiveness and are critical to strengthening information systems on a regional and national level. These are not new issues. In fact, the data limitations are common to most developing countries. The Initiative offers a unique opportunity to make timely and lasting improvements to information systems across the region. 2.3 Policy and Advocacy In the planning process, health workgroups identified major needs in both policy and advocacy. In general, workgroups describe the policy landscape in Mesoamerica as lacking cohesion, integration, and leadership. 35 Comments from advisors and examples from the literature give further support to the workgroup findings. Each health area would benefit from building a motivated constituency that includes advocates from inside government, civil society and academia/ research. Increasing skills and creating an environment for new policy dialogue in the region are also needed. A concerted effort at building advocacy capacity and pushing for targeted policy reform at national and regional levels can increase funding and political support for the Initiative s four health areas. Policy and advocacy activities fall under the umbrella of stewardship, leadership and governance. 36 This component of health initiatives and of health systems has been described as the most complex but critical building block 37 for success. Truly, it is a multifaceted issue of which policy is only one component. A larger discussion of strategies for good governance is beyond the scope of this report but will be necessary for successful implementation of the Initiative. 15

16 Main Limitations in Policy and Advocacy in the Mesoamerican Region 1. Need for Improved Advocacy, Leadership and Management Skills All four health workgroups discussed the need for improved skills in advocacy, management and leadership regionally. Lack of advocacy skills has historically limited the impact of other health programs in the region. For example, national immunization councils currently lack the influence to positively affect immunization policy. The lack of trained and passionate personnel able to advocate for new policies in other health areas contributes to a situation in which health policies are outdated, unaligned with needs, and often not enforced. Increased skills in advocacy will contribute to improved Initiative governance and to long-term sustainability of the Initiative s activities and impact. Pairing advocacy skills building with leadership and management training and support could have further positive impacts on the Initiative s governance. 2. Need for Updated Health Policies Many health policies in the Initiative s focal areas are outdated or not enforced. In nutrition, for example, outdated policies are cited as a barrier to successful implementation. Both the RMNH and Immunization workgroups cited similar problems. Legal frameworks for health information systems are also outdated, as discussed under Health Information Systems. Connection between research, or new evidence, and health policy development is lacking. There is a weak culture of the translation of research into practice via evidence-based programs or policies in Latin America. 38 In many cases, research priorities are directed by external funders rather than by existing program and policy needs, a paradigm that further hinders the process of developing evidence-based legislation. A 2006 paper explains, There is a need to establish research priorities at the country level in order to develop a national research action programme [sic]. 39 One reviewer supported this claim, [There is] a need for field research to generate evidence-based interventions which will help bridge the gap between policy makers and those on the front line carrying out the interventions. Regional alignment of priorities is also weak, and should be considered. Many existing health policies are poorly enforced. For example, policies about notifiable diseases are weak and rarely enforced, meaning many cases of communicable disease go unmonitored. It is widely agreed that policies without enforcement will have little to no impact. In summary, there is no regional health research agenda that can be translated to evidencebased policies and supported by effective enforcement mechanisms. 3. Need for Facilitation of New Partnerships Activities of several health workgroups will require partnerships across health areas and across sectors. Immunization and RMNH, for example, will rely on strong infrastructure to support their interventions. Nutrition and vector-borne disease control will depend on improved water and sanitation in order to reach stated goals. All health workgroups propose community outreach, interventions integrated into primary care, population-level education, and social mobilization. Delivering at these levels of the health system will require partnerships with many programs and sectors. Integrating efforts of the Initiative with existing health, development and social programs will potentially save costs and improve quality of service delivery. In essence, partnership, cross-sectoral communication, and joint strategy development will be critical to achievement of immediate and long-term goals. Recommendations for Policy and Advocacy Related to the Initiative 1. Coalition building Building coalitions across health focus areas and across sectors is essential to the success of integrated health programs. A successful coalition strategy will require collaboration across sectors of the government and partnerships with external partners including research 16

17 institutions, the public sector, the private sector, and multinational organizations like WHO/PAHO. NGOs should be central to partnership strategies because of their close relationship with target populations. NGOs have much to offer, including the capacity to develop realistic implementation plans, speak to the unique challenges of working in remote areas, share knowledge of indigenous culture, and share success stories In that may not be present in the literature. While NGOs in Latin America are currently not well organized, the region could benefit from an anchor organization that convenes partners, inventories services, and fosters peer learning. Representatives from target communities must be involved in program planning, evaluation, and policy development. The extent to which target communities are engaged will affect program outcomes and potential for long-term change. This strategy is well outlined in the Immunization Master Plan. Coalition building will require that multiple partners agree on plans and objectives and be willing to mobilize support for effective practices. For example, strengthening partnerships with the G20 and G8 could create a powerful lever for improving international fiscal policy related to development. Further leveraging the role of COMISCA and PAHO in the region will also be beneficial to furthering existing and new health and development programs. Partnership building can catalyze increased regional support for integrated approaches to health improvement. Successful integration depends on negotiating complex relationships, sharing information freely, and embracing a holistic approach to both program success and to health. Embracing integration provides opportunities for programs to work together, promotes collective thinking and problem solving, and supports working together in new ways so that the impact of all programs is improved. 40 Successful coalition building will require both facilitation and training, including courses in leadership and communication, at a regional level. order to produce longterm sustainable results, these prog rams should be carried out through the collaborative efforts of civil society, government and the Pan-American Health Organization (PAHO), and most importantly the people of the affected communities. Carlos Franco Paredes, et al. Commentary: improving the health of neglected populations in Latin America. BioMed Central. January 2007, 7:11. The planning phase of the Initiative set a precedent for crossborder collaboration. Many lessons were learned from this experience that can be applied to strengthening the process in the implementation phase. Without attention to developing a collaborative process by which initiative leaders interact, consider information, and make decisions, opportunities to strengthen this important horizontal element and ensure improved health regionally will be lost. Constructive and ongoing dialogue can ensure that the Initiative s activities are iterative, responsive to community needs, and rapidly scale-up successful innovations. During implementation, open communication between vertical programs will be essential to country programs. This exchange of information will enable program managers to monitor progress, share ideas, and make course corrections. In this initiative with bundled services, a common target audience on shared long-term goals, leaders and managers require new ways of working together. Managing an integrated program will require a shift from competition and secrecy toward collaboration and openness. These are learned skills now widely taught and increasingly 17

18 practiced in the US and around the world. In order to work together effectively, leaders and program managers can benefit from training in collaborative planning. The move from working in segregated silos to inside integrated programs can be facilitated by developing these skills among project leadership. 2. Advocacy skills building Advocacy skills building will create a new corps of people trained to apply data and program results toward improved governance and policy development. Building multiple layers of capacity at community, national, and regional levels will empower people living in Mesoamerica to advocate for the continuation of the Initiative s most effective activities beyond the planned implementation phase. 41 In addition to improved policy, advocacy training can facilitate shared regional learning related to data (surveillance information), program results, and necessary policy actions. As discussed in the following Community Participation section of this report, there is a long-standing practice of social mobilization and a strong civil society in Mesoamerica. These strengths can be leveraged, especially with targeted and strategic skills building, to improve the Initiative s impact on health equity. Advocacy skills will also translate to other areas of development, thus creating long-term, regional impact at the individual, organizational, and sector levels. 3. Development of policy goals and frameworks in the Initiative s health focal areas The Initiative has the potential to be catalytic if leaders develop policy goals and frameworks that align with broader national and regional agendas. The Initiative is one step in a larger regional movement towards improved health and development. Leading organizations, including COMISCA, have spearheaded the development of regional goals in health and other sectors. Progress toward the achievement of existing and new goals can be achieved through Initiative activities. New policy may update outdated legislation with laws that provide substantive support for effective practices in health. For example, policies may set national and regional standards for health goals and indicators, like the WHO standards in nutrition. Revisiting national policies in the context of a regional initiative may also align health and development goals at a larger scale in this sense, creating an economy of scale of political will and financing. Standardizing legislation at a regional level can have powerful impact on drug-purchasing power and supply systems development, especially if pharmaceutical and private sectors are included in policy development. Policies must not only be developed but also enforced. It is, therefore, necessary that enforcement and policy support mechanisms be put into place and followed. Conclusion Several needs in policy and advocacy were identified in the Initiative s planning phase, including: the need for advocacy skills building; the need for updated health policies; and the need for new partnerships. Workgroups, advisors and examples from the literature agree that the following activities could be employed to address needs: advocacy skills building; development of policy goals and frameworks; and coalition building. Together, these activities can contribute to broader and more sustained regional support for the Initiative s health focus areas and approach to increasing health equity. 2.4 Community Participation Community participation is essential to reaching vulnerable populations, to gaining their trust and to fully engaging them in the process of change. An appreciation of indigenous peoples world view is a first step toward understanding their health beliefs and behavior. Health programs that attempt to impose their beliefs and values from without are unlikely to succeed. Involvement with community leaders and respected community members, will enable the Initiative to gain their support for new, healthy behaviors, and ultimately the support of the community as well. This innovative perspective takes into account that 18

19 poverty is the driving force of underdevelopment and bad health; and promotes community participation as a leading strategy to counteract the effects of disease determinants 42. Community participation differs from the other horizontal elements in that it is a process. The Integration Framework for the Mesoamerican Health Initiative on (p. 8) illustrates how community participation should permeate every health intervention. This underlying operational principle should underpin all activities; creating partnerships between communities and health plan- Changing ners; and building capacity for partnered planning and implementation Community participation means considering communities as full partners rather than passive recipients of services, and then working alongside them to improve health conditions and behaviors. 1. Interventions are often designed to meet the needs of the funder and not the target population Interventions, especially those that are population-based, often do not reach the most vulnerable populations and predominantly benefit better-off segments of society. For example, the benefits of food fortification programs are not reaching indigenous rural communities who do not consume bread or tortillas made with commercial, fortified flour. Instead, fortified foods are reaching urban populations who prefer these types of products. Additionally, foods are fortified using adult nutritional requirements, which do not meet pre-school children s needs. By focusing on their population-based goals funders inadvertently increase the health inequities faced by the most vulnerable populations. social conditions to ensure that people have the freedom to lead lives they have reason to value would lead to marked reductions in health inequalities the active involvement of individuals, and communities, in decisions that affect their lives is crucial. 2. Interventions typically utilize a top-down, vertical approach Health interventions are often designed using a top-down approach that lacks an understanding of the realities of indigenous people living in rural areas. As described in the Immunization workgroup Master Plan, the reductionist approach of Western medicine often conflicts with the holistic cosmology of many indigenous communities. Western research methodologies tent to view such people as the subjects of research rather than partners in development. If these and other complex community Michael Marmot, Health in an Unequal World, The Lancet- Vol 368: Dec factors are not taken into account, even the best planned interventions are likely to fail. 3. Interventions are not consistent with what the community views as important and do not have the support of the local community. Funder priorities sometimes do not align with what the community thinks is important. As the Malaria workgroup Master Plan points out, some sociocultural characteristics of indigenous populations make it difficult to implement anti-malaria activities. No matter how sound an approach may be, if communities do not see the benefits of a particular approach or if competing needs are given a higher priority, the intervention will fail to some degree. The community must believe that the health issue is an important one. Unless communities and other key stakeholders see the merits, even the best-designed prevention strategies are unlikely to be effective. 19

20 4. Interventions are typically not linked to social change Civil society and social movements have a long and well-known history in Latin America. Unfortunately, given the top-down approach of many health interventions this strength has not been utilized to its full potential. Many health interventions are not designed to address the social determinants of health because they fall outside of the project s purview and/or the issues seem intractable. By ignoring social determinants, program planners miss a valuable opportunity to link their interventions and target population to social policies and strategies that improve health equity. In order to achieve planned social change in health the community must be recognized as the primary focal point for change. By linking social change to interventions, the community gains valuable knowledge on the issue that would not only lead them to change their own behavior, but also lead them to challenge existing social, political and economic systems that perpetuate their marginalization. Recommendations for Using Community Participation 1. Interventions should reflect the needs of the community, not the funders In order to reach the most vulnerable populations funders need to design interventions that meet their needs. This means they must start where the people are ; acquiring an understanding of the existing interests, the ideology, and the perceived needs of the community. It is imperative that funders realize that reaching the most vulnerable populations takes more time and resources than reaching better-off populations. To reach the target population funders must be flexible; provide the additional necessary resources; and be realistic when setting project goals and timelines. Participatory strategies, such as participatory rural appraisals, need to be developed and piloted in order to identify barriers; engage local opinion leaders; and develop culturally appropriate interventions. 2. Engage all stakeholders, including community members, program staff, and researchers, in a joint, cooperative process All of the master plans suggested that it was crucial to involve community partners in the implementation of interventions. Participatory processes that promote equal partnerships between all stakeholders and power sharing in all phases the interventions development and implementation help break the typical top-down, vertical approach to development. These processes take human behavior, socio-cultural, and economic factors into consideration in order to achieve a more integrated, horizontal, and, thereby, successful approach. 45 For example, in Panama the Ministry of Health hired social scientists to partner with community leaders to develop culturally appropriate breastfeeding campaigns. Partnering with NGOs is another way of identifying representatives of target communities and incorporating their view points in health systems planning. 3. Develop the community s capacity to assume greater responsibility for assessing their health needs and problems One of the most beneficial outcomes of participation is the heightened sense of community responsibility and conscientiousness. By engaging in collaborative processes community members gain influence through the acquisition of new skills and control over resources Community members, typically an untapped or underutilized resource, can provide valuable voluntary input to improve interventions. In turn this fosters the belief that they can make a positive difference, which leads to the community taking ownership of the intervention. Through this process, the community also gains knowledge which supports and reinforces desired behavior change Plan and implement solutions they have identified and prioritized Through the use of participatory methodologies, such as SWOT analysis and community mapping, program planners can work with the community to identify and prioritize their needs. Roll Back Malaria, for example, 20

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