Supporting Integrated Community Case Management (iccm)

Supporting Integrated Community Case Management (iccm) RBM Harmonization Working Group Meeting December 2-4, 2013 Dr. Mark W. Young Senior Health Specialist UNICEF, New York

Presentation Content The problem Why iccm? Financing opportunities for iccm What can countries do? Next steps 2

Each year, over 2 million children still die from pneumonia, diarrhea and malaria despite the availability of life-saving interventions The current rate of decline in under 5 mortality is insufficient to reach MDG 4 Under Mortality Decline Current and Projected Trends in 24 MCH priority countries One-third of under 5 deaths are caused by pneumonia, diarrhea, and malaria Global distribution of deaths among children under 5, by cause 6,000,000 5,000,000 Other 21% Pneumo nia 17% 4,000,000 3,000,000 HIV/AIDS 2% Diarrhea 9% 2,000,000 1,000,000 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Neonatal 44% Malaria 7% Scaling up interventions for pneumonia, diarrhea, and malaria is needed to help accelerate progress on MDG 4 Source: A Promise Renewed, September 2013 3

For malaria, there are opportunities to improve current diagnosis and management at the community level (1 of 2) The current scenario for malaria can lead to suboptimal health outcomes and inefficiencies in the system 4

For malaria, there are opportunities to improve current diagnosis and management at the community level (2 of 2) RDT rollout through CHWs, without the appropriate skills or medicines for comprehensive management, can lead to: More sick children receiving inappropriate treatment (or no treatment) ACT wastage - and therefore waste of (malaria) resources Drug pressure on malaria parasites Even for RDT+ children, further assessment is required due to significant overlap of malaria and pneumonia symptoms, and high rates of co-infection in many countries The current scenario for malaria can lead to suboptimal health outcomes and inefficiencies in the system 5

Agenda The problem Why iccm? Financing opportunities for iccm What can countries do? Next steps 6

iccm is an effective strategy for scaling up treatment of pneumonia, diarrhea and malaria at the community level Training and deployment of CHWs can increase coverage and access to treatment Critical program and health system components required: 1. Policies and Financing 2. Human resources 3. Supply chain management 4. Service delivery and referral 5. Communication & social mobilization 6. Supervision and QA 7. M&E-Health Information Systems 7

Benefits of integration over non-integrated approaches Access/coverage Early and appropriate treatment Increases care-seeking, service uptake and treatment coverage for malaria, diarrhea and pneumonia Increases timely treatment for all three conditions Quality Improves health worker skills & performance Efficiency Reduces inappropriate prescribing of ACTs Can reduce out-of-pocket expenses for transport to health facility iccm improves health outcomes and enhances program effectiveness and efficiency Source: GF TERG. Thematic Review of Global Fund s Contribution to MDGs 4&5. November 2013 8

% total appropriate treatment A growing body of evidence, together with country experience, underscores the benefits of the iccm approach 84% 70% Quality of care Comparison of quality of care for HEWs and higher-level health workers (Ethiopia) 53% 43% HEWs 72% 65% HF workers 54% 48% Timely and Appropriate Treatment %of children that received appropriate treatment Uganda Zambia 80 60 40 Key assessment tasks performed* Child correctly classified for iccm illnesses** Child with pneumonia correctly treated Quality of Care Indicator Child needing referral referred 20 0 Fever ARI Diarrhoea Baseline Endline Fever ARI Diarrhoea Equity Rational Use Equity: Utilization of CHWs by SES tertile (Cameroon) 66% 61% Low Middle High Febrile Children Receiving AL (Zambia) Received AL N (%) Did not receive AL N (%) Total N (%) 52% Cost savings associated Intervention 265 (27.5) 698 (72.5) 963 (100) with decrease in inappropriate ACT Control use 2066(99.1) 18 (0.9) 2084 (100) Total 2331 (76.5) 716(23.5) 3047 (100) 9

The Global Fund recognizes the importance of scaling up integrated approaches like iccm to improve the linkage between MNCH and its current investments Exploring options to maximize synergies with maternal and child health, the Board strongly encourages Country Coordinating Mechanisms (CCMs) to identify opportunities to scale up an integrated health response that includes maternal and child health in their applications for HIV/AIDS, TB, malaria and health systems strengthening. GFATM Board Recommendation 2010 GF NFM is a key opportunity for driving increased integration 10

Agenda The problem Why iccm? Financing opportunities for iccm What can countries do? Next steps 11

To date, GF investments in fighting malaria as well as HSS have played an important role in supporting the iccm platform Ethiopia used funding from Global Fund Malaria, Round 5 to deploy over 30,000 community Health Extension Workers who support not only HIV, TB and malaria services, community case management of malaria, pneumonia and diarrhoea, especially in rural areas; Malawi used funding from Global Fund HSS, Round 5 to reinforce its human resources for health with over 10,000 Health Surveillance Assistants who also provide community-based maternal, newborn and child health care (iccm) in hard to reach areas ; Uganda used funding from Global Fund Malaria, Round 10 to continue to scale up iccm through Village Health Teams (VHTs), building on the HMM experience from previous rounds.

A large effort is underway to harmonize the global response for RMNCH programs representing a key funding opportunity for iccm RMNCH-related funding streams World Bank, IDA/HRITF, RMNCH Trust Fund, UNICEF, USAID, H4+, and Global Fund (representing over $1 billion in potential funding over the next 2 years) Principles of country engagement Building on the principles of IHP+ To bend the curve towards achieving MDGs 4 & 5. To align and coordinate funding streams towards critical gaps Led by MOH, includes all RMNCH stakeholder: DPs, civil society, etc. To build on other major planning processes e.g. support for Health Sector Plan Key activities A joint, rapid multi-stakeholder synthesis of the RMNCH landscape that brings together the various RMNCH-related plans, subplans, initiatives, etc. Prioritisation across the entire RMNCH continuum of care Commitment of development partners to support implementation of prioritised interventions matching of existing and new funding streams to priorities and gaps 13

Aligning the NFM and RMNCH-related funding streams can create a win-win situation for malaria, HSS and MNCH Main Components of iccm Potential Funding Sources Malaria commodities (ACTs, RDTs) Malaria program (training, program mgmt, advocacy, M&E) iccm delivery (training, M&E, program mgmt) CHW platform (tools, enablers, HR) Pneumonia commodities (antibiotics, respiratory rate timers Diarrhea commodities (ORS, zinc) Global Fund RMNCH Trust Fund Domestic resources/ health sector budget World Bank UNICEF Additional donors (TBD) Greater impact on child mortality Improved cost efficiency of malaria program Leveraged donor resources 14

Essential ingredients of iccm and eligibility for Global Fund support Essential iccm Components Training and salary costs for community health workers RDTs for malaria diagnosis ACTs for malaria treatment Respiratory timers for pneumonia diagnosis Antibiotics for pneumonia treatment and ORS and zinc for diarrhoea treatment Supportive supervision Supply chain system strengthening Health information system strengthening Global Fund Supported Yes, provided that these community health workers are also directly involved in malaria management Yes Yes No* No* Yes Yes Yes * Commodities not funded by the Global Fund provide a co-funding opportunity for governments or other development partners to invest into the iccm platform Source: 2013 RBM HWG Country Briefing Note

The RMNCH country engagement process aims to build off other major planning processes (including GF) to ensure financing of comprehensive Health Sector Plan External financing Domestic financing Gap Gap-filling complementary resources Total funding needs of RMNCH-related strategies & plan(s) Bilateral funding X +X WB IDA/HRITF Bilateral funding Y Other Bilateral funding International NGOs/Foundations Other sources +IDA/HRITF Multilateral support (e.g. H4+) RMNCH TF +UN +GF GAVI Global Fund Domestic resources 16

Agenda The problem Why iccm? Financing opportunities for iccm What can countries do? Next steps 17

Aligning with the HWG malaria process, a clear articulation of iccm needs will be required; countries are encouraged to prioritize gaps in their NFM submissions iccm Standard Summary Gap Table iccm Commodity Costs Need Financed Gap ACTs RDTs ORS Zinc Amoxicillin Respiratory Rate Timers Additional iccm commodities iccm Delivery Costs CHW Platform Costs CHW Tools & Enablers CHW Recruiting, Training, Data, and Program Management Advocating for an integrated approach in country: Identify needs, costs, and gaps (iccm summary gap table), leveraging HWG process Ensure broadbased MNCH representation on country decisionmaking mechanisms Prioritize gaps in NFM submissions (malaria, HSS) and other RMNCHrelated proposals as appropriate In addition to indicative funding (malaria and/or HSS), a well articulated and presented integrated plan can increase the likelihood of support from additional funding sources GF Incentive Funding Stream or other non-gf sources 18

Agenda The problem Why iccm? Financing opportunities for iccm What can countries do? Next steps 19

What is needed to accelerate financing and implementation of iccm Technical support for comprehensive iccm gap analysis and development of technically sound/evidence-based iccm strategy Identification of needs and mapping of existing and potential sources of funding Clear articulation of integrated strategy and need, incorporated into GF NFM submissions and within overall Health Sector Plan Ensure broad-based MNCH partnerships, and representation on country-level decision-making mechanisms UNICEF (and partners) discussions with GF on support for process and co-financing will be actively pursued on a countryby-country basis for selected number of countries The iccm community is mobilizing TA to support process in collaboration with HWG 20

Summary More is needed to bend the curve on MDG 4 and reduce preventable child deaths from pneumonia, diarrhea and malaria The Global Fund recognizes the importance of scaling up integration through its malaria and HSS investments in order to maximize contributions to MDG 4 Integrated Community Case Management (iccm) improves health outcomes, coverage of life-saving interventions, and overall efficiency and quality of the health system for both malaria and broader MNCH programs There is a significant opportunity to co-finance iccm through GF and additional RMNCH-related funding streams creating a win-win situation With a clear articulation of iccm strategy (needs, costs, and financing gaps) countries have potential to leverage various funding streams to ensure delivery of a comprehensive intervention package Strong in-country MNCH partnerships will be needed to drive this agenda forward 21

THANK YOU! 22

Appendix 23

Community case management for each of the three conditions is known to be highly effective Area Reduction in Mortality, U5 % Other relevant outcomes/comments Community case management of pneumonia All children 2 Children with disease 24 36 Cost per death prevented as low as $2.64 3 Recent study shows a reduction as high as 70% 4 Diarrhea treatment n/a ORS may reduce mortality up to 93% 10; Zinc is estimated to reduce diarrhea mortality by 23% 12 BRAC Bangladesh increased ORS coverage up to 81% through CHWs/Oral Rehydration Extension Program Worker 9 Integrated community case treatment of malaria 8 All children Children with disease 40 60 In recent Madagascar trial with RDTs, 98% of all childhood cases were cured 7 Severe malaria 53 Home-based newborn care Stillbirths 1 16 29 Includes range of services: Umbilical cord care, initiation of breast feeding etc. 6 Participatory women s groups facilitated through CHWs have shown ~30% reduction in neonatal mortality 5 1 Lassi ZS (2010); 2 Sazawal S (2003); 3 Bang AT (1990); 4 Theodaratou E (2010); 5 Manandhar DS (2004), Tripathy P (2010); 6 Lassi ZS (2010) 7 Ratsimbasoa (2012); 8 Kidane G (2000), Sirima SB (2003); 9 NIPORT (2012); 10 Munos MK (2010); 11 Huber D (2010); 12 Walker CL (2010)

Furthermore, nearly two-thirds of newborn and child deaths could be avoided if essential care was provided along the continuum of care Source: PMNCH Continuum of Care, 2010. 25

The integrated approach can lead to Health System Strengthening (HSS) across critical program components Integration of training from outset helps to avert missed opportunities : integrated training from day one helps to ensure balance in treatment of multiple conditions Integration of supervision: separate vertical program supervision results in waste of resources, especially when the same front-line health worker is delivering all of these services Integrated, well-functioning supply chains central to successful service integration: despite support for integration at policy and program level, and highquality integrated training, coverage and quality remain poor if supply chain is weak Addressing demand-side barriers critical to uptake of integrated services: despite integrated services, uptake for many crucial interventions often low Integrated HMIS and M&E creates efficiencies and can improve program impact: weak and fragmented M&E across multiple levels of the system (involving both data collection systems and HR capacity) major constraint to scaling up integration iccm can contribute to all disease specific programs/components and/or cross-cutting HSS (or even incentive funding)

Estimated timeline for next steps Activity Advocacy & resource mobilization UNICEF (and partner) discussions with GF/other donors on support for process & co-financing iccm community to mobilize TA to support process (in collaboration with HWG) Identifying iccm needs Provide standard guidelines, assumptions and tools for gap analysis TA to select countries for completing gap analysis and update iccm strategies/plans Complete iccm gap analysis (align with HWG process) Incorporate iccm & gaps into national plans 2013 2014 Dec Jan Feb Mar Apr May Jun NFM HWG/iCCM Workshop NFM indicative funding announced Initial NFM concept note submissions Funding request for integrated plans Prioritize iccm strategy, needs and gaps in NFM concept note and other donor proposals Global activity Country activity 27