BUILDING SUSTAINABILITY
FROM
THE BASE
Building a Bottom-up Approach to Health
in a
Hierarchical System
The LCCN/GHM Partnership
David M. Thompson, MD MPH
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CONTEXT
Country rich in resources but with poverty
& health indices comparable to
surrounding much poorer countries.
Mature church (2 million strong) with
abundance of trained & educated people
State health employees on strike for
several months
Continuing cholera epidemics
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HEALTH CARE IN NIGERIA
Traditional care & market
Levels of government service:
Tertiary: Federal Med. Cntrs. & University Hospitals
Secondary: State General Hospitals
Primary Health Care: Local Government (counties)
Local Government Authorities (LGA’s)
Good plans with multiple layers of organization
Politicized & overpromised
Under funded
Poor communications & feedback cycles
Private clinics/hospitals
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LCCN HEALTH SERVICES
Firstmissionary, Dr. Bronnum, was a
medical doctor
Health services important
History:
General hospital taken over by gov’t ’71
22 Dispensaries 15 functioning today
3 Maternities 2 functioning today
29 Health Posts 1 functioning today
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PARADOX
The Church & Health Services
Church grew over 100 year period to 2
million members
Onceimpressive church health service
almost disappeared
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TRANSITION FROM MISSION TO
CHURCH OWNERSHIP
(Looking in from the outside)
Assumed not planned or questioned
Organizational/management structure
ambiguous & weak.
Highly trained missionary personnel
replaced by entry level Nigerian staff
Inadequate funding, supervision,
transportation, continuing education
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TRANSITION FROM MISSION
TO CHURCH OWNERSHIP
Complicated by:
Increasing complexity & cost of institutions &
professional cadres
Professionalization & specialization of health
services.
Lack of local identity & ownership
Unstable political environment
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SOLVING THE DISEQUILIBRIUM
COMMUNITIES INDIVIDUALS
FAR NEAR
POOR RICH
INSTITUTIONAL CENTERS
Tertiary
Secondary
Primary
Communty-Based
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BUILDING SUSTAINABILITY
FROM
THE BASE
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IN THIS CONTEXT
Sustainability, What does it mean?
Base:
What is it?
Where is it?
What is its makeup?
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Partnering to Rebuild
LCCN Health Services
Four pronged approach
Water program (WASH) ongoing.
Capacity building of existing institutions
CBPHC through an integrated development
model
Malaria
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The Base is Interconnected &
Interdependent Communities
The LCCN institutional system was not
connected in a vialable way to their communities
Community-Based-Primary Health Care:
Broadens the support of LCCN health
services by connecting them to communities
Creates ownership of shared health goals at
the community level
Promotes an approach focused on population
as well as individual health visible results
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COMMUNITY-BASED
PRIMARY HEALTH CARE
CBPHC has been very successful in
improving health in low-resource settings
CBPHC is effective with potential to cut:
Childhood death rates in half
Birth rates in half
Rates of childhood malnutrition by 80 – 90%
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IMPACT
Changes in Health Indicators
(Jamkhed 1971-2006)
200
180
160 IMR/1000
140 CBR/1000
120
ANC/Del.
100
80 FamPlan
60 Immun.
40 Malnutr
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0
1
6
6
6
9
6
81
91
97
97
98
99
99
00
19
19
*1
*1
*1
*1
*1
* = data collected *2
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CBPHC Program Principles
Service as a witness rather than a tool.
Sustainability through community
engagement, empowerment & ownership.
Self sufficiency
Equity
Holism
Interdependency
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THE PROCESS/STORY
Preparatory team visits 2006 & 2007
PHC training session 2009
Visits to Chanrai Foundation PHC project
Visit to SCMS Léré, Chad
Agreementbetween GHM & LCCN Health
Board Memo of Understanding 2009.
GHM leadership team visits Jamkhed
Comprehensive Rural Health Project Jan ‘10
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PROJECT PLANNING 2010
Using Jamkhed as a Model
Meeting with representatives of church
leadership, organizations, Dioceses, Ministry of
Health & LCCN health workers.
Subgroup visit to all Dioceses in Adamawa &
visits to proposed pilot project sites.
Subgroup selects 2 pilot project sites.
Agreement formalized & team members
selected.
Teams trained at Jamkhed Feb 2011
Team training in Nigeria March 2011
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WHERE ARE WE TODAY?
Establishing ownership at all levels:
LCCN leadership
LCCN Health Board
Mobile Leadership Teams
Community
Two pilot projects launched April 2011
Good start
Unlearning old Top-Down habits & learning Bottom-
Up skills community ownership & empowerment
Cycles of learning & adjusting
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Sustainability*
has 3 aspects that can &
Sustainability
should be measured:
Economic: Are financial resources available &
improving?
Ecologic: Is change improving or depleting
natural resources?
Values: Is culture changing in ways that
increase a shared community identity &
cohesiveness or not?
*Future Generations SEED-SCALE model
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Sustainable Change*
Fueled by human energy
Enabling behavior change at community level
Creating partnership:
Community - Outside expertise - Government
Making sure all voices, including women, in the
community are heard & utilized
Generating locally gathered evidence & data
*Future Generations SEED-SCALE model
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Sustainable Change*
Building on previous community successes
Iteration: (promoting cycles of
learning/improvement)
Interdependence instead of dependency
Growth beyond the community – going to
scale
*Future Generations SEED-SCALE model
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The SEED-SCALE* Criteria For
Assessing Results
Equity
Sustainability
Holism
Interdependence
Iteration
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RESOURCES
CRHP Jamkhed: http://www.jamkhed.org/
http://www.youtube.com/watch?v=AZYsI_tWydY
Global Health Ministries: http://www.
Future Generations: http://www.future.org/
http://www.seed-scale.org/
USAID Basics: http://www.basics.org/
USAID eLearning Center:
http://www.globalhealthlearning.org/login.cfm
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RESOURCES
with Dr Halfdan Mahler:
Interview
http://www.who.int/bulletin/volumes/86/10/
08-041008/en/index.html
BangladeshRural Advancement
Committee: http://www.brac.net/index.php
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