La Paz Pneumonia & Diarrhea Demonstration Collaborative
The La Paz Pneumonia and Diarrhea collaborative seeks to improve treatment and care and reduce mortality for children under 5 with pneumonia and diarrhea by improving referrals to health clinics, integrated community case management, and better provision of initial treatment and follow up care. The collaborative’s aim was to achieve delivery of first treatment dose in the community by a health volunteer for 100% of children under 5. The collaborative also sought to provide follow-up care within 48 hours for 100% of children treated for pneumonia or diarrhea at a health unit participating in the collaborative.
The La Paz collaborative implemented changes at both the community level and facility level. While the facility changes discussed were implemented across the department, the community changes that truly drove the success of this collaborative were first implemented in the Marcala district in the department of La Paz, which were later were expanded to other districts.
HCI trained 22 CESAMO clinics, clinics staffed by a doctor, and 5 CESAR clinics, rural clinics not staffed by a doctor, as well as one maternity clinic. These changes were instituted at facilities and in communities simultaneously. The impetus for change came from the local maternity clinic in Marcala (CMI), which was the only clinic in the area that provided care 24 hours a day. A major initiative in the collaborative was to reorganize the provision of care among the health units and clinics in the area so that they could better work together and distribute caseloads. Because the CMI did not have the funds or resources to treat sick children, it served as a proponent for organizing the collaborative to promote care at the CESAMOs. It also helped organize the referral system, training activities, and monitoring by facilities, and offered guidance and motivation for other health units. As a result, the CESAMOs now provide emergency care for sick children.
At the beginning of the collaborative, facility staff were given a review of how to use run charts to track pneumonia and diarrhea cases. In addition, facilities developed pneumonia and diarrhea treatment flowcharts and introduced a triage protocol. When a sick child arrived at the clinic with a referral, he or she received priority treatment. The facilities began to track community referrals by registering them in a notebook. Standardized referral forms for better documentation and protocols for rehydration for 4+hours and follow-up within 48 hours were also re-designed and introduced. Clinic health staff educated mothers of treated children about the causes of pneumonia and diarrhea at the time of their consults in order to promote prevention of the diseases in the community. The CMI offered housing to children and their families in the maternity waiting home when these children needed further follow-up after care. The health network provided the necessary logistical support to mobilize staff to support community work by the committees. The Canadian Red Cross was also working in the area, and provided significant support to the community committees. Clinic health workers were compensated for their time spent in the communities, which provided an incentive for them to work overtime. One clinic staff member was designated as a leader and liaised with the communities. Finally, the Secretary of Health, USAID, and the clinics signed a “management agreement,” outlining the processes to be completed and provided funding. The management agreement provided motivation among staff and helped encourage more referrals.
While the facility changes discussed were implemented across the department, the community changes that truly drove the success of this collaborative were first implemented in the Marcala district in the department of La Paz, which were later were expanded to other districts. At the community level, community management committees were formed in 11 communities in the Marcala area. Members included community leaders in the areas of water and sanitation; schools; local government; community health workers, including midwives and children’s growth promoters. First, a community and facility surveillance system for pneumonia and diarrhea was implemented. All members of the committee were responsible for finding and referring sick children. USAID and the Canadian Red Cross offered the committees donated medicines and seed money. After the committees were formed and created work plans, members were trained in community integrated management childhood illness (IMCI), specifically the prevention of pneumonia and diarrhea, to recognize danger signs in children under 5, and provide initial treatment. They were also provided referral forms, a referral tracking notebook and forms to document monthly community committee activity. The Canadian Red Cross donated a cell phone to each committee, which is used to phone in referrals to health unit personnel, creating a cellular communication network in the area. Both the community committee members and the health clinics were provided with a list of phone numbers to call for referrals. The phones allow communities to phone ahead to the clinic to alert staff that a sick child will arrive. The Marcala health center staff regularly visited each community to analyze and supervise referrals, and the community committees also received support from Environmental Health Technicians, or community health workers employed by the CESAMOs , who attended monthly committee meetings. These technicians help lead the committees as well as provide training to them in conjunction with local nurses; additionally, they monitor water and sanitation systems in the communities. The communities were provided with stocks of oral rehydration solution and antibiotics from the Marcala maternity clinic in order to initiate treatment for sick children. To prevent stock-outs, they monitored their levels of medications and re-supplied monthly as necessary from the clinic. Children received follow-up within 48 hours of their visit; if the child could not travel to the health clinic, a community volunteer visited the child at home.
The HCI team developed and field-tested seven indicators to measure progress under the collaborative. The indicators related to correct treatment and correct registration documentation by health unit staff. Key indicators are as follows:
• % of children under age 5 treated in the health unit whose growth and development chart was completed and updated during the visit
• % of children under age 5 with a pneumonia diagnosis treated in the health unit that received correct protocol treatment using antibiotics
• % of children with a diarrhea diagnosis treated in the health unit that were evaluated, classified, and treated according to dehydration grade
• % of children under age 5 with a pneumonia or diarrhea diagnosis that received initial treatment in the community as indicated under the UNICEF’S integrated community case management (ICCM) strategy
• % of children under age 5 with a pneumonia diagnosis treated at the health unit who received follow-up care within 48 hours of treatment
The La Paz collaborative developed a service delivery model and created organizational changes within the maternity clinic and the participating CESAMOs. The learning sessions helped foster operational knowledge of best practices among clinicians in the participating facilities.
The 11 participating communities in Marcala were especially successful in reducing mortality. As a result, their best practices were implemented in a sub-collaborative in an expansion phase that included 10 new communities in the Marcala health network, as well as the communities served by 9 health units across three nearby health districts including 13 CESAMO facilities. The Marcala team presented its achievements and process to other health districts to share its results. During the expansion phase, new teams visited Marcala and accompanied the Marcala committees on visits to communities to observe their practices. New teams also visited the Maternity Clinic in Marcala to understand first-hand the referral process and the involved documentation. The Marcala team also presented its findings and lessons learned during trainings and workshops for the sub-collaborative.
The La Paz region, one of 18 departments in Honduras, has a total of 68 health units that serve a population of 198,000, including 21,886 children under 5. There is one hospital, two maternity clinics (CMI), 2219 health centers staffed by a doctor (CESAMOs), and 47 rural health centers not staffed by a doctor (CESARes). These are organized into 3 health networks. In addition to the maternity clinic, 27 units participated in the collaborative, including 22 CESAMOs and 5 CESARes.
Many of the successful community level interventions described in this report were implemented in 11 communities in the Marcala district; these were the interventions spread to 10 other sites during the expansion phase of this collaborative in 2010, and 9 additional communities in 2011. In the Marcala health network, there are 9 health units, comprised of 1 maternal clinic, 3 health centers staffed with a doctor (CESAMOs) and 5 health rural health centers (CESARs).
The community committees were supported in technical areas through training on related pneumonia and diarrhea topics at the beginning of the collaborative, as well as through regular supervision visits from health unit personnel each month to verify correct provision of initial treatment for pneumonia and diarrhea. With regard to QI methods, the teams were trained during learning sessions on the use of standard evaluation system (SES) tools, synthesis, and how to incorporate the use of databases and daily documentation.
The Canadian Red Cross provided support to the community committees and support for the inter-municipality exchanges. HCI financed incentives for the community committees and organized a yearly meeting for the communities and the clinics.
The collaborative held four learning sessions in 2009 and 2010 to promote learning and sharing among the participating facilities. Clinic staff participated in the sessions, led by HCI and regional and central level staff from the Secretary of Health’s Integrated Child Health Program (PAIN). It was fundamentally important to have the participation of the PAIN staff at the beginning, especially to foster institutionalization. Each meeting included presentations by each health facility to share their results, knowledge sharing and feedback by participating units, and discussions of various units’ challenges and lessons learned; regional surveillance data on pneumonia and diarrhea-related mortality were also presented. A participant from SESAL documented each learning session, which greatly contributed to synthesizing and sharing knowledge. The sessions included both technical information and discussions of quality improvement methods. Later learning sessions included monitoring and evaluation of to-date project results and surveillance in the communities. The community committees also gathered twice per year to share their experiences, led by the health facility staff. The committees themselves met monthly in their communities.
At the yearly National Quality Conference, the Marcala presented team presented their results, and teams from the Comayagua region decided to implement the same changes. Comayagua then visited Marcala and implemented a similar system.
The most striking outcome of the La Paz collaborative was a stark decrease in children’s pneumonia and diarrhea related mortality. At baseline in 2008, 17 children died from pneumonia and diarrhea in the surveyed area. In 2009, the first year of the collaborative, this was reduced to four deaths. In 2010, there were five total deaths; however, a long rainy season caused a sharp rise in pneumonia incidence that year. Remarkably, the Marcala health units were still able to limit pneumonia and diarrhea associated mortality even while the number of pneumonia cases reached levels high above the designated “alarm” stage. In 2011, there were only two deaths in Marcala due to pneumonia and diarrhea combined. However, there were still 19 deaths that year in the whole La Paz region. Overall, the number of community referrals has doubled each month. With no community treatment at baseline, by the end of the collaborative, 100% of children with pneumonia or diarrhea received initial treatment in the community and a referral to a health unit.
The experience of the Marcala communities provides several lessons learned for other facilities and health regions trying to achieve similar declines in pneumonia and diarrhea mortality in children. First, it is critical to involve the community in addition to health workers; while buy-in from health facilities is important, the participation of community members is truly critical. The collaborative found that providing follow-up care within 48 hours after treatment helped improve patient outcomes. The collaborative hopes to involve community health workers in providing follow up care once the children have arrived home in order to improve this indicator. It was also challenging to maintain sufficient supplies of medications in the community at times; if the clinics were stocked out, the communities were as well. Maintaining a consistent antibiotic and oral rehydration solution supply might require coordination with higher levels in the Ministry of Health; other basic medical supplies, such as a chronometer to measure respiration, would also be very useful for community members to evaluate children prior to referring them to a clinic. The Canadian Red Cross donated chronometers to the community, as well as more general health job aids and references.
In order to provide training for the local community committees, the QI team had to partner with cooperating agencies that worked at the local level, such as the Canadian Red Cross, which was involved with the work of the communities and community health workers. During the first phase, there were no funds from HCI or the CQI teams to provide monetary incentives for the community health workers or to expand the improvement activities to other communities. However, there was a lot of motivation for the project because the results are clearly visible to the entire community. Monthly community volunteer meetings were also helpful to synthesize the experiences of each team, evaluate progress to date, encourage continued participation, update work plans, and continue learning within the community.
Some identified best practices from the project included:
1. Community organization
2. Training of volunteer community health workers
3. Re-organizing clinic services to better facilitate triage of sick children
4. Communication with health centers by telephone to alert the facility that a sick child was en route
5. Creating space for sick children and their mothers to stay at the maternity waiting house by the maternal clinic
6. Improvements to the information system to promote better record keeping
7. Monthly monitoring of indicators