Moyo Wa Bana

A novel approach to reducing child mortality in Zambia

This document was produced by Camilla Hebo Buus for CARE International Zambia with the financial support of the Government of Canada provided through the Canadian International Development Agency (CIDA) Cover photos: CARE Canada/Terri-Sue Buchanan Printed by New Horizon Printing Press

May 2013

Moyo Wa Bana
[health of children]

The Moyo Wa Bana project championed a novel approach community-led and user-owned to reduce the persistently high morbidity and mortality of under-five children in Zambia. This is the story of Moyo Wa Bana.

Moyo Wa Bana is one of the projects that have managed to make a real impact on IMCI in the project areas. Vichael Silavwe, Chief IMCI Officer, Ministry of Community Development, Mother and Child Health

Growth monitoring in the shade of a tree: It is difficult to maintain regular growth monitoring of children in many areas of Zambia - especially during the rainy season (Image: Terri-Sue Buchanan)

IMCI
The Integrated Management of Childhood Illness (IMCI) strategy was developed by the United Nation Childrens Fund (UNICEF) and World Health Organization (WHO) in the early 1990s. It is a holistic approach to child health, which recognizes that children brought for medical treatment in the developing world often suffer from more than one condition. The strategy includes both curative and preventive measures that are implemented by families, communities and health centres. IMCI seeks to reduce child mortality and morbidity, as well as improving growth and development during the first five years of a childs life. The strategy includes three main components or pillars: (1) improving case management skills of health care staff, (2) improving overall health systems and (3) improving family and community practices for home management of illness. In health centres, the IMCI strategy promotes the accurate identification of childhood illnesses in outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers, and speeds up the referral of severely ill children. A cornerstone of IMCI is a set of clinical guidelines. When assessing a sick child, a combination of individual signs leads to one or more classifications, rather than to a diagnosis. IMCI classifications are action-oriented and allow a Health Worker to determine if a child should be referred to another health facility, if the child can be treated at the first-level facility, or if the child can be safely managed at home. In the home setting, IMCI promotes appropriate care-seeking behaviours, improved nutrition and preventative care, and the correct implementation of prescribed care. Since its introduction, IMCI has been accepted by many countries in the world, including Zambia in 1996. In fact, Zambia was one of the first countries to train health service providers in IMCI, with a number of adaptations made to the generic UNICEF/WHO IMCI guidelines and manuals to make them more appropriate to Zambias health service needs and its policies. These have included a revision of the malaria treatment guidelines and the incorporation of HIV guidelines.
More information about IMCI on https://apps.who.int/chd/publications/imci/res. htm and http://www.who.int/maternal_child_adolescent/topics/child/imci/en

What is IMCI? 1

A nurse sees children at a growth monitoring point erected during the Moyo Wa Bana Project (Image: CARE)

Why Moyo Wa Bana?

Zambias child mortality rate is amongst the highest in Southern Africa. At least 1 in 8 children die before they turn five in Zambia (see table). According to WHO/UNICEF, most deaths after the neonatal period result from pneumonia, malaria, diarrhoea, HIV&AIDS and measles, often with malnutrition as the underlying cause. Yet, most of these diseases are preventable and treatable through simple, affordable interventions. However, many parents struggle to provide their families with proper nutrition and adequate healthcare on a daily basis. Many child deaths are due to inadequate knowledge and/or inappropriate treatment by caretakers. Zambia has adopted IMCI and put in place an enabling policy framework for child health, but progress in providing healthcare and IMCI services to children has been slow (CARE MWB CBI Project Implementation Plan 2008). The country has less than half the health staff it needs, and in Child mortality in Zambia (deaths per 1,000 live births) Under-five mortality rate Infant mortality rate 1992 190.7 107.2 1996 197 109 2002 168 95 2007 119 70 2010 138 76 MDG 2015 goal 63.6 35.7 many rural health centres there are only one or no skilled Health Workers. They are instead manned by unskilled staff (Classified Daily Employees). All in all, very few of them have received training in Integrated Management of Childhood Illness (IMCI). The problem is exacerbated by shortages of drugs and essential supplies, as well as recurrent restructuring of the health system (CARE Mid-Term Evaluation of MWB CBI 2011). Addressing the high mortality of children in Zambia is a massive task. The Moyo Wa Bana Project was set up to strengthen existing healthcare of children under five as provided by the Ministry of Health. The goal was to improve the health of children through the development of sustainable, equitable and holistic child health services. Through the implementation of IMCI, Moyo Wa Bana championed a community-based and userowned approach, which proved very successful in improving child health.

Though mothering is a traditional role, additional technical support is required to ensure quality life for the child. Cathryn Mwanamwambwa, CARE Regional Director of Programmes

Source: Zambia Demographic and Health Surveys. The Millennium Development Goal (MDG) is the national goal for Zambia.

Why Moyo Wa Bana? 3

Background
The Moyo Wa Bana Project, undertaken with the financial support of the Government of Canada provided through the Canadian International Development Agency (CIDA), is one of the longerrunning donor-funded projects in the health sector in Zambia, spanning a period of 15 years: Phase 1 | Infant and Child Mortality Reduction Project | 1998-2000 The preliminary phase of Moyo Wa Bana, the Infant and Child Mortality Reduction Project, tried out several direct interventions for IMCI-service delivery and capacity building at community and health centre levels, backed by strengthened medical and logistical supply chains. It targeted three districts (Lusaka, Ndola and Kasama). Phase 2 | Moyo Wa Bana Integrated Management of Childhood Illness | MWB IMCI | 2001-2007 The second phase of Moyo Wa Bana consolidated the direct interventions applied during the Infant and Child Mortality Reduction Project, continuing the work in Lusaka, Ndola and Kasama Districts. This phase focused on improving Health Worker performance and the community-IMCI (C-IMCI) component, as well as on assisting Health Managers at District Health Offices with developing systems to support IMCI implementation. Phase 2 demonstrated how to implement IMCI in a Zambian context, including assisting the Ministry of Health in developing country-appropriate training and support packages. Specifically, MWB IMCI succeeded in developing a strong C-IMCI model (IMCI component 3), and therefore in improving IMCI case management (IMCI component 1), resulting in better child health in the project districts. However, the project districts became somewhat dependent on Moyo Wa Bana and its inputs and technical support. Moyo Wa Bana did little to explicitly transfer capacity to districts and other levels of the Ministry of Health for them to manage, monitor and coach Health Managers and Workers and ultimately assume responsibility for IMCI in the project areas and replicate it in others. Thus, towards the end of Phase 2, it became clear that in order to promote sustainability, ownership had to be further encouraged at all levels of the health system (IMCI component 2). Phase 3 | Moyo Wa Bana Capacity Building Initiative | MWB CBI | 2007-2013 The third phase of Moyo Wa Bana focused on ensuring the sustainability of community-IMCI services in Zambia through increasing support to partners in the health system. By supporting capacity building of institutions rather than individuals, MWB CBI sought to enhance and expand

4 Background

the role of all levels of the Ministry of Health in strategic management and leadership of child health and IMCI. The main thrust was to build capacity of the Child Health Unit at central level to support Provincial Health Offices, and for these to support District Health Offices, to ultimately support Health Workers in health centres and communities engaged in IMCI. However, the third phase also continued the health promotion programme initiated in the previous phases, backed by interventions to strengthen medical and logistical supply chains. Through tailored experiential learning, MWB CBI continued the efforts to develop workable and affordable community-based models for child health and IMCI, by assisting district and health centre staff in institutionalizing better systems for reaching communities. MWB CBI was a four-year project with a two-year extension. It worked in eight districts (Kapiri Mposhi, Serenje, Mansa, Milenge, Samfya, Kasama, Mungwi and Mporokoso) initially, but added another three districts (Mumbwa, Kawambwa and Mpika) in the extension phase. Throughout its 15 years, Moyo Wa Bana worked in 13 of Zambias 103 districts, in 6 of its 10 provinces targeting about 2.5 million children and their families.

Level of Intervention
The Moyo Wa Bana project worked at every level of the health system in Zambia, avoiding the creation of parallel and hence unsustainable structures.
Central Level
Child Health Unit

Clinical Care Specialists Maternal and Child Health Coordinators

Provincial Health Offices

District Health Offices

Maternal and Child Health Coordinators

Nurses Clinical Officers Environmental Health Technicians

Health Centres

Neighbourhood Health Committees Traditional Healers

Community Leaders

Child Health Promoters Community Health Workers

Volunteers

Beneficiaries
Under-five children, their families and communities

Background 5

Moyo Wa Bana - training outreach

Training

The Moyo Wa Bana Project trained nearly 6,000 Child Health Promoters and 1,200 Health Workers in IMCI in its 13 project districts as indicated on the map (Child Health Promoters Health Workers)

Luapula Province

Northern Province
Mporokoso 26328 8042 Kawambwa

Mungwi 27639 Kasama 962214

Muchinga Province

Mansa
309 Samfya 87 201 27651

Northwestern Province

Copperbelt Province
Ndola 1256262

15 Milenge

Mpika 5717

Serenje 29946

Kapiri Mposhi 46948

Central Province

Eastern Province

Western Province

Mumbwa 14724

Lusaka 1985316

Lusaka Province

Choice of Districts Southern Province

The 11 rural districts participating in Moyo Wa Bana were chosen primarily due to having some of the highest under-five mortality rates in Zambia.

6 Overview of Moyo Wa Bana

Meet a community volunteer

Isaac Knox Sindazi, 57, lives with his wife and children in Musa Village, 15 kilometres from Kasama in Northern Province. He is a Child Health Promoter: I was among the first community volunteers to be trained as Child Health Promoters by the Moyo Wa Bana project in Kasama in 2002. Since then, I have seen great improvements in family and community health practices. This is why I cannot stop serving my community even when the project ends. Let me give an example from my own family: Previously my family did not value the importance of good hygiene. As a result, especially our youngest children experienced frequent episodes of diarrhoeal diseases. Now I have learned to cover the pit latrine and I sprinkle ash to prevent flies. I also started boiling water or adding chlorine in order to kill germs. And we now practice hand-washing both after using the toilet and before eating. I live as role model in my community. This gives me morale and energy to give health education to my community, and they have responded positively, and the end result has been less diarrhoeal cases in my community. Another positive change is the construction and renovation of growth monitoring and promotion shelters in the community. These are within walking distance, which has led to most mothers bringing their children for weighing, unlike in the past when they were discouraged by having to walk long distances to the health centre. Other volunteers stopped a long time ago because of lack of incentives. They used to laugh at me. But I enjoy community work, especially seeing the under-five children growing well and strong. The mothers have also encouraged me not to stop. Due to my hard work, the District Health Office enrolled me for training as a trainer of community IMCI. I can now train other Child Health Promoters and Neighbourhood Health Committees, and I feel good, because knowledge is power. I was also given a bicycle by the Moyo wa Bana project, which I use to monitor and supervise child health promoters, and to follow up sick or defaulting children. I also received an umbrella and a bag for my documents. In the mornings I usually do some work in my banana orchard, and on Sundays I go to church, but I spend most of my time doing community work, including distributing family planning pills, condoms, chlorine and treated bed nets. During weekends I am mostly free, and I use this time to conduct home visits.

Isaac Knox Sindazi weighing a child at the health centre (Image: CARE)

Case Story 7

SUCCESS: Reduced morbidity and mortality

Level of Intervention
Central Level Provincial Health Offices District Health Offices Health Centres Community Leaders Volunteers Beneficiaries
Under-five children, their families and communities

Integrated Management of Childhood Illness (IMCI) has three objectives: 1. Reducing infant mortality. 2. Reducing the incidence and seriousness of illnesses and health problems that affect children. 3. Improving growth and development during the first five years of a childs life. All the 13 project districts involved in Moyo Wa Bana reported reductions in the number of infants and children falling sick (morbidity) and dying (mortality). In addition, national data points to declines in many project districts for both incidences and case fatality rates of some of the major causes of death, including malaria, pneumonia and diarrhoea. In Kapiri Mposhi, for example, a project district since 2007, the malaria morbidity fell, from 468 per 1,000 children in 2007 to 97.5 in 2012. This was most likely due to better prevention through family/community participation. Secondly, the malaria case mortality fell, from 287 per 1,000 children in 2007 to 21.7 in 2012. This was likely due to better case management, ensuring timely and appropriate treatment.

However, these trends were far from clear-cut across all project districts, as improvements were linked to the intensity of the interventions. Therefore, progress was particularly noticeable in Lusaka, Ndola and Kasama, the three districts involved in Phase 2 (MWB IMCI), as this phase focused on direct IMCI delivery. During Phase 3 (MWB CBI), support was shifted to capacity building in the health system. In addition, Moyo Wa Bana also assisted in reducing and stabilizing the proportion of underweight children in the project districts. Mporokoso, for instance, a project district since 2007, recorded a drop in underweight children from 14 percent in 2008 to 1 percent in 2011. Many of these improvements were linked to observed behaviour changes for prevention at family/community level, including use of insecticidetreated mosquito nets and chlorine for water purification, hand-washing and proper construction and siting of pit latrines.

8 Successes

Care-seeking behaviour
Key to the achievements of the Moyo Wa Bana project was its ability to change behaviour in the communities. At baseline, most caretakers believed in the traditional myths and taboos of the diseases. This has changed. Not only are the communities now using preventative measures such as bed nets, safer drinking water, hand washing and breastfeeding, they are also exhibiting a clear care-seeking behaviour, avoiding delays in accessing skilled healthcare. This manifested itself clearly in the increase of referrals of very sick children.

Moyo Wa Bana has activated the communities; they are now demanding health services. Nalisa Mwaka, community focal person and trainer of trainers in Northern Province

Successes 9

3.5 kilometres from Nchimishi Rural Health Centre in Serenje District, Melody Chibuye (centre), a mother of three and grandmother of four, went out of her way to thank the health centre (represented by the centres Clinical Officer Ernest Mankomba (right) and CAREs Central Province Coordinator Martha Chiwete (left)). Ms Chibuye is certain Moyo Wa Bana saved the life of one of her granddaughters, aged 3 , who was very sick with pneumonia: Now, we hear of less children dying, she explained (Image: Camilla Hebo Buus)

SUCCESS: Engaged communities

IMCI component 3: Improving family and community practices for home management of illness

The Moyo Wa Bana Project was successful because it managed to break an otherwise entrenched barrier for how to reach beneficiaries. Traditionally, communities have played an inactive role in the day-to-day provision of health care. Community members would go to health centres when in need, usually referred by Traditional Healers at a late stage. However, Moyo Wa Bana succeeded in energizing communities to embrace modern healthcare through community-based health services in synergy with local health centres. The project empowered communities to actively manage their own health. The project used existing Ministry of Health structures to reach the communities, working closely with Neighbourhood Health Committees. The committees would assist in identifying, training and supervising volunteers selected to work as Child Health Promoters. The volunteers were mostly recruited from amongst already skilled groups such as Community Health Workers and Traditional Birth Attendants. Each member of a Neighbourhood Health Committee would supervise a zone, divided into units, and each unit would be chaired by a Child Health Promoter, who would report back to the committee member. The demarcation of zones into units was a very thorough process, driven by the communities, which involved determining how many households would be manageable for each volunteer. According to guidelines from the

Ministry of Health, there should be one Community Health Worker for every 500 households. In actual fact there are a lot fewer. Moyo Wa Bana increased this density dramatically: Urban Child Health Promoters covered between 120 and 150 households, while their rural counterparts were assigned between 30 and 75 households. This helped to reduce the need for expensive modes of transportation and improved information dissemination. The Neighbourhood Health Committees would report back to the health centres, where the project trained Health Workers as focal point persons for supervision of and support to community volunteers. At household level, the Child Health Promoters provided health education to mothers and other members of the community. This included information on child health and diseases, nutrition, hygiene, sanitation, family planning and sexually transmitted diseases such as HIV&AIDS. Demonstrated successes include increases in caretaker knowledge and practices on the prevention of diseases, as well as in home-based management of uncomplicated cases. At community level, Child Health Promoters would weigh, monitor and assess children at designated growth monitoring points. Sick children would be referred to a health centre and followed up

Level of Intervention
Central Level Provincial Health Offices District Health Offices Health Centres Communy Leaders
Neighbourhood Health Committees Traditional Healers

Volunteers
Child Health Promoters Community Health Workers

Beneficiaries

Before we saw 150 children a day. Now we only see 30 to 50. Ernest Mankomba, clinical officer-incharge at Nchimishi Rural Health Centre, Serenje District, on the impact of community volunteers

Successes 11

The community volunteer system is a unique feature of Moyo Wa Bana. And it worked so well that other NGOs would contact us to learn what we did. At one time our then Country Director even jokingly said that we were a mini university of community systems and engagement for other organizations! Martha Mwendafilumba, CAREs Moyo Wa Bana Project Manager (2006-2007)

by the promoters afterwards. In addition, Child Health Promoters did the groundwork for underfive sessions such as immunization campaigns by identifying and organizing children in need of vaccination before the arrival of Health Workers. This shortened the sessions to the benefit of both Health Workers and caretakers.

Most important, however, is that Moyo Wa Bana has clarified the roles and responsibilities that volunteers can play in supporting the health system. Being part of the communities, the Child Health Promoters were accepted as health agents; a role that traditionally was reserved for Traditional Healers. This breakthrough has a big potential in future health interventions, if replicatPreviously, growth monitoring was an irregular ed countrywide. event, especially during the rainy season, as it was often carried out under a tree. Now, desig- Moyo Wa Bana trained close to 6,000 Child nated growth monitoring points were established Health Promoters and 270 Traditional Healers within the communities through the construction in IMCI, as well as nearly 1,200 Neighbourof proper shelters, frequently initiated or sup- hood Health Committee members in Communiported in kind by the communities. CARE provid- ty-IMCI supervision. ed basic medical equipment such as scales, health charts, under-five growth monitoring cards and registers. In addition, the project contributed plastic, cement and nails towards construction of growth monitoring points. Demonstrated successes included a considerable improvement in the number of caretakers regularly accessing growth monitoring points. In addition, the project observed a decrease in the referral for preventable diseases such as malaria, diarrhoea and pneumonia, thereby helping to decongest health centres and reduce Health Workers work-load. Meanwhile, the project saw an increase in the referral of very sick children to health centres and onwards to hospitals, proving that both communities and Health Workers had learned to identify danger signs necessitating prompt referrals.

Serenje growth monitoring point before and after (Images: CARE)

12 Successes

Meet a community member

Gift Ngosa, 43, lives with his wife and four children in Soweto Compound in Kapiri Mposhi, Central Province. He volunteers at the TAZARA Clinic about 1.5 kilometres from his home: The source of livelihood for my family is through me doing a few hours of casual work at the TAZARA railway station on Wednesdays and Sundays. The wages are hand to mouth, mostly used to buy food enough for a day or two, so we are struggling as a family to meet most of the basic needs of life. But I have benefitted a lot from the Moyo Wa Bana Project and so has my family and indeed the entire community. The Child Health Promoters always visit us to give us health education. Beforehand, we had little information on prevention of childhood illnesses like diarrhoea through safe waste disposal, hand washing and others. The Child Health Promoters also help us in siting wells and toilets, and have told us the importance of separating wells and toilets to avoid contaminating underground water. I fight hard to find food to feed my family to avoid malnutrition, and we try to buy chlorine for the chlorination of water to prevent diarrhoea. We also sleep under mosquito nets to avoid malaria, and I have managed to maintain the size of my family due to family planning messages I receive from the clinic and the Child Health Promoters.

But my week is actually occupied with a number of child health activities. I participate in a number of health programmes under the Ministry of Health, like prevention of mother-to-child transmission (PMTCT) counselling, the orphans and other vulnerable children (OVC) project and mental health activities. On Mondays, I attend under-five sessions at the TAZARA Clinic. I counsel mothers, and I test and weigh children. On Tuesdays and Thursdays, I do OVC activities. I joined the OVC team after receiving training in Kabwe. All of us in the community now seek early treatment of common diseases like malaria, coughs I do most of these jobs on a voluntary basis, and and diarrhoea, and this has led to fewer deaths I do enjoy my routine activities. However, I still and less children getting sick. need more cash, since a number of my children are going to school, and I need to pay their school At one time the Child Health Promoters referred fees as well as food and clothing. As a family we my youngest son, who is two years old, to the face a lot of challenges like poor housing, lack clinic, when he had diarrhoea that almost killed of safe drinking water, poor roads, lack of food, him, and one of my neighbours daughters could poor sanitary facilities and unemployment. have died, if she had not been referred.

Gift Ngosa with wife and two children outside his house (Image: CARE)

Case Story 13

Community volunteers without remuneration

The local response to Moyo Wa Bana was tremendous. Child Health Promoters are volunteers who receive no remuneration. Yet, they put in hours of their time, travelling long distances, motivated by their desire to see healthy children. Peggy Mwambazi is one of them. She used to walk for seven hours to the nearest clinic when her children needed a medical check-up. Today, she needs just five minutes to get to the free growth monitoring point set up by community members through the Moyo Wa Bana project. After seeing the benefits of the project, Peggy volunteered to become one of the thousands of CARE-trained Child Health Promoters working to improve the health of children in their communities. I wanted to help other women, said Peggy and added: Not everyone can afford to go to a clinic. Moyo Wa Bana is free, and it comes to you. The job as volunteer proved successful in another way. The volunteers became respected in their communities as health agents, bringing with it a certain amount of status. This kept many volunteers motivated, despite the lack of remuneration, but also promoted gender equality through empowerment of women, as they took on new public roles within their communities.

Child Health Promoters checking underfive cards for children (Image: CARE)

Successes 15

SUCCESS: IMCI-skilled Health Workers

IMCI component 1: Improving case management skills of health care staff

Level of Intervention
Central Level Provincial Health Offices District Health Offices Health Centres
Nurses, Clinical Officers and Environmental Health Technicians

Despite Zambia beginning to implement Integrated Management of Childhood Illness (IMCI) in 1996, it still has very few Health Workers trained in IMCI. National saturation levels are only about 28 percent. Moyo Wa Bana aimed at achieving saturation levels of 80 percent and it succeeded in most of the project districts, typically reaching levels of above 90 percent (see map on next page). In Mporokoso, for instance, the saturation level went up from 4 percent in 2007 to 100 percent in 2012. However, saturation levels will likely reduce in the future as some Health Workers are transferred, while others leave or die. IMCI training was given to a wide range of Health Workers rather than concentrating solely on personnel trained in clinical medicine. This had the added benefit of putting everyone on the same level. It also improved coordination and communication between health staff in the districts. The initial training was followed up with refresher courses as well as technical support and supervision. The latter proved very important for motivation. Without follow-up, Health Workers would eventually ignore what they had learnt. Initially, supervision was carried out by CARE, but later it was done by the districts with minimal input from Moyo Wa Bana. The project put great em-

phasis on providing incentive-based rather than compliance-based supervision (carrots rather than sticks), with the excellent results achieved providing sufficient motivation. Many health centres created designated child health stations to optimize the time spent in the health centre by caretakers and their sick children. Instead of going from Health Worker to Health Worker for temperature taking, weighing and examination, they received the whole package in one location. CARE also supported the efforts through provision of basic IMCI equipment and essential IMCI drugs, which could not be provided by the Ministry of Health. As a result, health centres in project districts are now providing holistic care (a more systematic and thorough screening, diagnosing and treatment of sick children) instead of only attending to caretakers complaints. Even the most basic health centres are now using their IMCI chart booklets. Improved case management resulted in better diagnoses and treatments. Antibiotics are no longer prescribed for everything, and all fevers are no longer automatically treated as malaria. The Ministry of Health has noted an increase in accountability and rational drug use in health centres where Health Workers have been trained in IMCI.

Communy Leaders Volunteers Beneficiaries

16 Successes

In addition, improved case management resulted in shorter consultation and waiting times, less referrals to higher-level health institutions and a reduction in the recalls to health centres. Importantly, the Moyo Wa Bana Project improved the relationship between the health centres and the communities in their catchment areas. Previously, the role of the Health Workers was to wait for patients to come to their centres, treating them as need arose. Moyo Wa Bana made the relationship reciprocal. IMCI-trained Health Workers made an effort (and had more time) to counsel caretakers rather than just treating the children having discovered the importance of community involvement in prevention and referrals. In addition, Child Health Promoters would submit household data to health centres, making it a lot easier for health centres to plan, budget and gauge progress of IMCI outreach activities. Moyo Wa Bana trained nearly 1,200 Health Workers in IMCI, as well as many Health Workers as focal point persons in Community-IMCI supervision and both Health Workers and District Health Managers in IMCI supervision.

Now I am able to make correct assessments of all sick children. I use the IMCI chart booklet to classify and give correct treatment, and I am now able to switch to second-line treatment with little or no consultations. Mordecai Palangwa, an Environmental Health Technologist at Chishamwamba Health Centre in Mporokoso District, who, due to shortage of staff, was screening patients without any medical training until he attended IMCI training under the Moyo Wa Bana Project

80 percent of the success of Moyo Wa Bana is down to constant monitoring. Health workers see a lot of patients; without monitoring, shortcomings will creep in. Doctor Tiza Mufune, District Medical Officer, Serenje District

Successes 17

Moyo Wa Bana - saturation levels

National average:

28%

Luapula Province

Northern Province
Mporokoso 75% 100% Kawambwa Kasama 85% Mansa 100% 100% Milenge

Mungwi 100%

Muchinga Province

89% Samfya

Northwestern Province

Copperbelt Province
Ndola 52% (2007)

Mpika 95%

Serenje 85%

Kapiri Mposhi 84%

Central Province

Eastern Province

Western Province

Mumbwa 98%

Lusaka 40% (2007)

Lusaka Province

Southern Province

Saturation level Percentage of Health Workers managing sick children trained in IMCI. Zambia seeks to obtain a level of 80%. All Moyo Wa Bana figures are from 2012, except for Lusaka and Ndola (2007). National saturation level is from January 2013 (Ministry of Community Development, Mother and Child Health)

18 Overview of Moyo Wa Bana

The Moyo Wa Bana Project put emphasis on maintaining high saturation levels for IMCI-trained health staff in its project districts (Image: CARE)

Meet a team of volunteers

The Mumbachala Rural Health Centre, 215 kilometres west of Kapiri Mposhi, is run by Mr Mutale, a clinical officer. He is supported by 3 unqualified staff, namely Blitter Ensakalika, 34 (top); Bonavandrus Chilibumbi, 35 (centre); and Ginard Punta, 30 (bottom). This is their story: able to screen children eligible for vaccines at the under-five clinic, which helps to decongest the centre during immunization sessions.

(Images: CARE)

We have all been to school, and are able to understand the basics of medicine. Bonavandrus attained Grade 12, while Blitter and Ginard went up to Grade 9, and Blitter has also been trained as a The three of us have been taught by Mr Mutale. Child Health Promoter under the Moyo Wa Bana After he underwent training in IMCI, he has been Project, so she can screen children well for childtraining us through clinical meetings on good hood illness, and treat them better than before. case management of childhood illness, orientations and actual practice. When we make mis- Our way of life on a daily basis is somehow routakes, he is there to help us and guide us. tine. When we come for work, two of us do the sweeping, and the third one is a watchman. If Mr What led to this mentorship was the fact that Mutale is not around, we make a timetable of how Mr Mutale would be overwhelmed with doing all we should work while he is away. We divide roles the procedures of screening patients and dispens- in his absence, and assign ourselves duties. ing medication, and sometimes he is away at a workshop, attending to family issues or may be The source of income for all three of us is our sick. This left the centre with no one to attend to work at the centre. Although we are not on govsick children. ernments payroll, we are paid through the centres monthly imprests, but we also have small Now, that we have knowledge on case manage- farms, as the income is insufficient to meet our ment of childhood illness, we can ease his work families needs. load. When there are a lot of patients, we assist by seeing children in a separate room, and we The Moyo Wa Bana Project has helped us acquire can also attend to children in his absence. The new skills, so that we now are able to attend to three of us are able to refer and give pre-referral uncomplicated cases at the centre with confitreatment to very sick children by following the dence. This has earned us a lot of respect from IMCI guidelines in the chart booklet. We are also the community.

20 Case Story

Meet a Health Worker

Hector Makwaza is a male nurse who runs a rural health centre called Kapalala in Milenge District, Luapula Province, single-handedly. He was posted to Kapalala in 2008: I was taught that my job as a nurse was to provide nursing care to my patients. It was very exciting, and I looked forward to doing the same after graduating from nursing school. To my surprise, I was posted to go and man a centre, which was being run by a female employee with no formal health training. Naturally, she handed over literally everything to me, and the community had high expectations. More often than not, I helplessly watched children die from childhood illnesses such as pneumonia, malaria and diarrhoea. I hardly had time to rest. Queues of patients waiting to be seen could not be exhausted, often forcing me to miss lunch, and most of these cases I saw hurriedly and as such I miss-managed most of them. It was very common to see a case coming in the day after in a more severe state. My centre was always under-performing on child health indicators such that during performance assessments I never impressed anyone. I never looked forward to these performance assessments because to me it was an embarrassing exercise. However, from the time I received IMCI training, things have changed. I now see my patients, especially children, with more confidence. I see them, not just for the reason they are brought for care, but also for other problems, which the caretaker may not have noticed yet, and manage them holistically. This has reduced the chances of my patients coming back the following day, and as a result, caretakers have more time to attend to their economic activities, and I have sufficient time to rest, because queues are reduced. Right now I dont remember when I last had an in-patient death from childhood illness, and child health indicators have improved tremendously to the extent that my centre is now a shining example in the district, if not one of the best in the province. I owe this to Moyo Wa Bana.

Case Story 21

SUCCESS: Embedded ownership

IMCI component 2: Improving overall health systems

Level of Intervention
Central Level
Child Health Unit

Provincial Health Offices

Clinical Care Specialists Maternal and Child Health Coordinators

An essential component of the third phase of Moyo Wa Bana was to institutionalize IMCI in health management in Zambia. Otherwise the excellent achievements would have gone to waste. Thus, seconded project coordinators were based by CARE at central, provincial and district offices in order to maximize learning opportunities and transfer ownership of IMCI delivery, as well as to document the actual level of effort needed to support child health and IMCI. The CARE staff worked directly with and under supervision of the Ministry of Health staff to facilitate joint planning, budgeting, implementation and monitoring of IMCI. Most of CAREs project staff was withdrawn during 2010, leaving only three Provincial Coordinators, yet all levels improved their ability to plan and deliver IMCI capacity development and supervision to Health Workers.

District Health Offices

Maternal and Child Health Coordinators

Health Centres Communy Leaders Volunteers Beneficiaries

All levels were encouraged to take ownership, helped along by a user-driven planning process, including action plans at all levels, accompanied by regular planning meetings and reporting. The planning process was bottom-up, as communities would design annual action plans for health interventions, including IMCI, which would be included by districts in their action plans, which would be submitted to Provincial Health Offices. Participatory planning is a prerequisite for sustainability of a project like Moyo Wa Bana. CARE therefore also sought to include all relevant Health Managers in the design of Moyo Wa Bana and the planning of IMCI services to ensure full collaboration of government partners. The Moyo Wa Bana Project furthermore built on the existing health system and policy framework, including the National Health Strategic Plan and IMCI strategies. Thus, it avoided introducing extraneous processes that might be difficult for government to adopt at the projects close.

22 Successes

Evidence-based health management

An excellent interface was created between districts, health centres and communities, as Moyo Wa Bana succeeded in integrating the supply (health system) and demand (communities) of health care. Inspired by the successful Tanzania Essential Health Interventions Project (TEHIP), which recognized that healthcare funding is not always allocated to cost-effective health interventions guided by the burden of disease, Moyo Wa Bana began to collect data at community level to feed into planning and budgeting in the health system. Monthly meetings were called by health centres for Neighbourhood Health Committees and Child Health Promoters to discuss data, referral and follow-up support for under-five children and to address any difficulties. The communities collected data such as births, deaths and disease burdens, which would be submitted by the Neighbourhood Health Committees to the Focal Point Persons at health centres and onwards to the District Health Offices for analysis and interpretation. As a result, project districts increasingly carried out evidence-based planning and decisionmaking for child health with IMCI as an integral part of their planning cycle and resource allocation. Higher levels engaged in regular IMCI planning and budgeting as well, but they are still to reach the same level of evidence-based integration, partly because community data has not yet been included in Zambias Health Management Information System (HMIS). When community data flows from districts to provinces and onwards to central level, government will be better equipped to allocate funds according to the real burden of disease in Zambia.

Successes 23

Moyo Wa Bana energized communities to embrace modern healthcare (Image: Terri-Sue Buchanan)

Meet a Health Manager

Dr Knoziack John Chisenga, 50, is the District The most distressful thing in my practice has Medical Officer in Kasama District, Northern been to see a clinician mismanage a simple case of dehydration. Many times I have used the simProvince: ple classification method of dehydration provided Before I was trained in IMCI, I was very critical by IMCI to save childrens lives. There is nothing of the terms that are used in IMCI, such as very wrong with the classification of under-five child severe disease, as I did not believe in them as a illness going hand in hand with diagnosis of illmedical officer. However, when I was told that I ness, as this makes the process easier and faster would undergo training, I started reading about in some cases. IMCI, and when I was trained in 2006, by the Ministry of Health with support from the Moyo By embracing IMCI, we medical officers can imWa Bana Project, I came to acknowledge the val- prove the way we handle small cases. Knowlue of the IMCI strategy. edge of IMCI helps save the lives of children, as danger signs are easily noted at community level As one who has had to impart skills to student to allow for early treatment. In this way, IMCI clinical officers, I have used the IMCI skills to helps to bridge the gap between the elite and the make them understand some of the things I community. wanted them to learn. My training in IMCI has also improved my supervision of lay people or staff with no medical background. Overall, I have used IMCI on many occasions to manage a good number of common conditions.

Dr Knoziack John Chisenga believes the IMCI strategy is a useful tool for medical officers (Image: CARE)

Case Story 25

The real beneficiaries of the Moyo Wa Bana Project (Image: CARE)

10 transformations - by Moyo Wa Bana

The Moyo Wa Bana Project observed a range of transformations on the ground during its 15 years. Here are the top 10: 1. Improved health-seeking behaviour in communities with caretakers increasingly taking their children to either the Child Health Promoter or health centre within 24 hours of falling sick; 2. Improved caretaker knowledge and practices on the prevention of diseases, including home-based management of uncomplicated cases; 3. Reduced distance to health services with improved attendance as growth monitoring and related interventions such as immunization campaigns were brought into the communities; 4. Reduced work load for Health Workers as Child Health Promoters handled growth monitoring and related activities, as well as collected statistics in the communities; 5. Improved Health Worker skills manifesting itself in reduced patient re-attendance at health centres, rational drug use and holistic assessment of children; 6. Improved referral system IMCI-skilled Health Workers, professional and volunteers alike, were capable of identifying danger signs necessitating prompt referrals to the next level in the health system; 7. Improved relationship between communities, health centres and districts as Moyo Wa Bana integrated the supply (health system) and demand (communities) of health care; 8. Improved evidence-based planning and decision-making for child health with IMCI action plans becoming a common feature in project districts; 9. Improved stakeholder coordination for IMCI activities; and 10. Improved child health!

Overview of Moyo Wa Bana 27

Looking ahead: Ensuring sustainability

There will be casualties after CARE pulls out, but most will be picked up.

Nalisa Mwaka, Community Focal Person and Trainer of Trainers in Northern Province

The overarching concern for a donor-funded IMCI has proven to be a tool for strengthening project like Moyo Wa Bana is what happens when the overall health system as it introduces best funding is no more. practices, interventions and routines with a positive impact beyond child health. It is an excellent Generally, it is expected that reductions will be model for capacity building at community level, observed in saturation levels for trained Health which can be applied by other interventions. Workers and volunteers due to attrition and hence in the health indicators. However, Moyo Wa Accordingly, the Ministry of Health has assumed Bana has been around long enough for it to be some of the financing necessary to sustain Comable to develop a more sustainable system for the munity-IMCI activities. From the IMCI provision in future. their annual budgets, Districts Health Offices are now providing some of the data collection tools The project has not invested in parallel structures, and other stationery required by Child Health Probut in the existing health system. The volunteers moters. In addition, health centres in project disare not doing their work for CARE. Neither are tricts are assisting Child Health Promoters with the Health Workers or the Health Managers. They stationery, as well as repair and purchase of spare do it because they see that IMCI makes sense. parts for bicycles used for child health activities. Even though Moyo Wa Bana pulled out of Lusaka and Ndola in 2007, the work is still continuing The Ministry of Health has managed to keep IMCI in these two districts. The passion for change re- on the agenda, despite being both understaffed mains. and underfunded. All of its strategies and plans now include IMCI and for a reason: The project succeeded in creating multi-disciplinary teams (IMCI trained and oriented staff) IMCI may be a relatively expensive health inat all levels of the health system. Not only did tervention due to the demand for continuous this promote shifting of tasks downwards in the training, but in the long run, it is cheaper. Not chain all the way down to community level and only because it is financially cheaper to preindividual caretakers. It also ensured that a criti- vent rather than treat but because the lives cal mass was created for IMCI implementation, as of infants and children are saved. everyone now knows about IMCI. This means that if someone leaves, someone else will take over to some extent.

28 Looking Ahead

Looking ahead: Working with volunteers

Moyo Wa Bana relied heavily on volunteers. The project provided them with work-related requirements such as bicycles, bags, T-shirts and stationery, and experimented with refunding lunch and transport, but Child Health Promoters received no personal remuneration. Despite their incredible efforts, this is unsustainable in the future. Initially, the project envisaged that Child Health Promoters would work 2-4 hours per week, but it quickly became evident that they put in a lot more of their time. Recognition, status and certificates can only provide incentives for so long in particular considering that many volunteers in fact belong to vulnerable groups in society. Some volunteers therefore began to look for financial incentives, especially from other projects, which provided remuneration. This also meant that many of them ended up with very busy schedules, as the same volunteers were selected by several projects due to their existing knowledge on health-related issues. Income-generating activities were encouraged but not directly funded by Moyo Wa Bana (volunteers would receive training and support). These activities were only successful in some areas. Few volunteer groups managed to embark on incomegenerating activities profitable enough to sustain them, while others failed completely to raise start-up capital for such activities. Working with un-paid volunteers also presents another problem, as there is no way of holding them accountable for carrying out their work in a timely and correct manner. It is in the interest of all stakeholders in the health system; the Ministry of Health, the Ministry of Community Development, Mother and Child Health, donors, civil society and the private sector; to come up with common guidelines and approaches to address this problem into the future.

Looking Ahead 29

Looking ahead: Need for continuous training

We have to congratulate CARE on maintaining those saturation levels. More trainings were always conducted to fill the gap. Vichael Silavwe, Chief IMCI Officer, Ministry of Community Development, Mother and Child Health

The high turnover of Health Workers, professionals and volunteers alike, makes the continuous need for training a weak spot of IMCI. Training sessions are complex, involving 6 modules, 8 trainers and 8 days. Therefore, it would cost about KR150,000 (US$30,000) to train about 30 people almost half the monthly budget for a district such as Serenje Health Office.

Another success was the training inventory, updated by the Child Health Unit, which increasingly was used by Provincial and District Health Offices to guide decisions on staff placements to ensure IMCI coverage. It also ensured that the same people were not being repeatedly trained. More, importantly, government has now included IMCI as a subject in pre-service as well as inservice training. The National Health Community Health Worker Strategy includes IMCI training in the one-year course for Community Health Assistants, and the Chainama College of Health Sciences, one of the largest training institutions for Health Workers in Zambia, has included IMCI training in its syllabus for Clinical Officers in 2013. This means that all new graduating Health Workers will be trained in IMCI.

A key success at provincial level has therefore been the establishment of IMCI training teams in an effort to decentralize training. The goal was at least one team, consisting of three IMCI trainers, in all project provinces. This has removed the need for bringing in external trainers, and hence drastically reduced the cost. More importantly, in-province training teams are essential to future sustainability, as districts can now train Child Health Promoters on their own, without support from CARE. One outstanding challenge is a lack of IMCI training and orientation of Health Managers. IMCIBy experimenting with various forms of training, trained Health Workers will have a limited impact the Moyo Wa Bana Project also established that, in the long term, if they do not receive supportcontrary to beliefs, non-residential IMCI training ive supervision and monitoring by trained Health (part time) was in fact as effective as residen- Managers. The value of technical support and sutial training (full time). The huge cost of training pervisory visits has been voiced at all levels of could therefore be countered by supplementing the health system as being essential to ensure formal training with informal orientations for quality of service provision and future sustainparts of IMCI and/or for fewer participants. Some ability of IMCI and child health services. districts joined hands, pooling their resources, to gather enough participants for a full course.

30 Looking Ahead

ICATT can cut training costs

ICATT (IMCI Computerized Adaptation and Training Tool) is a software application to support the implementation of the WHO/UNICEF strategy on Integrated Management of Childhood Illness (IMCI). The tool provides the possibility to adapt the generic IMCI guidelines at national and sub-national levels, and to develop ICATT-based training courses that can be used in many ways, such as self-learning, classroom teaching and distance learning. The Moyo Wa Bana Project supported the introduction of ICATT as part of the IMCI training at Chainama College of Health Sciences. The self-learning, especially as part of refresher training, is particularly attractive due to low saturation levels for IMCI-trained Health Workers. While the lack of computers with the appropriate software and drivers installed to support ICATT throughout the country is a challenge, both in pre- and in-service training, there is great potential for such more efficient processes of training to be scaled up in the future.

Looking Ahead 31

Looking ahead: Other actions for impact

Lack of everything Like other healthcare services in Zambia, IMCI is a victim of the general lack of resources in the health system. When considering challenges, all Moyo Wa Bana districts first reported a lack of something, from stationery such as under-five cards, to equipment such as weighing scales and thermometers, to bicycles for Child Health Promoters. While IMCI is an effective tool in identifying cost-effective health interventions in the long term short-term focus must be directed to the lack of basic necessities, such as under-five cards. Bana found that health-seeking behaviour is usually led by a male head of a household or community, which can result in delayed healthcare. On the other hand, if a man takes a child to a clinic, treatment is rendered more quickly. In Moyo Wa Bana districts it became common to have female heads of Neighbourhood Health Committees, however male involvement in taking children to health services remained a challenge. Advocacy has a strong role to play in this regard, depicting woman in decision-making and men in caretaking. Moyo Wa Bana also confirmed that boys are expected to be tough, and may receive less cuddling than girls, who are expected to help in the house. It is therefore important to disaggregate Spread the word Because resources are limited and priorities many, child health data in Zambias Health Management advocacy for child health and IMCI resources is Information System (HMIS). important if these services are to be sustainable. Advocacy will have to take place at multiple Engage the private sector levels, including districts, provinces, Ministry of Greater impact could be achieved by exploring Health and Cooperating Partners, to ensure in- public-private partnerships to boost public funds creased allocation of funding and human resourc- with resources from the private sector. Concerns es to child health and IMCI in Zambia. Nation- about poor case management and IMCI mismanwide, this approach could be boosted through the agement by private practitioners will also have to use of prominent people such as District Commis- be addressed by developing a policy for regulasioners, or the First Lady given her active support tion of the way private practitioners manage IMCI for maternal and child health. In this connection, service provision and data. it is important to remember that Moyo Wa Bana has demonstrated that iterative and consultative Strengthen the Child Health Unit approaches to policy and advocacy work are the The capacity of the Child Health Unit for effective IMCI delivery and oversight is underpinning the most effective in the Zambian context. roll-out of IMCI in Zambia; however the delivery of effective institutional capacity development Gender affects children as well As IMCI seeks to improve the health of children, has been a challenge. Ongoing capacity developmale and female alike, gender mainstreaming is ment at central level will support the strategic essential. Generally, women are involved in IMCI oversight, management and coordination of child as mothers, caretakers, volunteers and Health health necessary for effective interventions. LesWorkers, while men appear in leadership positions sons learned can then be used to better advocate in the communities and health system. Moyo Wa for and institutionalize IMCI in Zambia.
32 Looking Ahead

Gender mainstreaming is essential to the sustainability of the Moyo Wa Bana Project (Image: Terri-Sue Buchanan)

Institutions involved in Moyo Wa Bana

The Moyo Wa Bana Project was implemented by CARE International Zambia through the Ministry of Health, starting from health centres, through District and Provincial Health Offices, to the Child Health Unit at national level. Funding amounting to a total of CAD$17.3 million (about KR90 million) was provided over 12 years by the Canadian International Development Agency (CIDA) through CARE Canada to CARE International Zambia. Both CIDA and CARE Canada provided technical, management and financial support.

We will continue! I cannot see an under-five child without using the IMCI guidelines. Constance Luhana, IMCI facilitator and trainer of trainers in Serenje District

34 Institutions Involved

For further information, please contact: CARE International Zambia 9 Chitemwiko Close, Kabulonga, P.O. Box 36238, Lusaka, Zambia Tel: + 260 211 267950-54/267958-59 Fax: +260 211 267956/57 Email: info@carezam.org