IGC – Workshop, July 2015 Maputo Marcos Vera-Hernández University College London

1. Pesquisa Científica na Área de Cuidado de Saúde Primários Scientific Research in Primary Healthcare IGC – Workshop, July 2015 Maputo Marcos Vera-Hernández University College London

2. Improving child nutrition through information provision • Malawi, Kenya, Nepal, India • Health insurance as the centerpiece of effective integrated healthcare • Colombia

3. Importance of nutrition 0-2 years old • Difficult to catch up any deficit that occurs in the early years • Future resilience to illness • Brain formation

4. Causes of malnutrition are complex • Common “unhealthy practices and norms”: • Misinformation, lack of knowledge • Social and family pressure

5. Examples of “unhealthy norms” Michinji (Malawi) • It is not good to give eggs to children • The soup broth is more nutritious than the vegetable and meat

6. Examples of “unhealthy norms” Western Kenya • Belief that if children eat eggs, their speak will be delayed • Meat causes allergy to children • Small children are better off eating plain and clear porridge without other foods

7. Effective and intensive communication • Deeply rooted beliefs • A leaflet will not solved the problem • More elaborated communication is necessary

8. Home visiting in Michinji (Malawi) • Maimwana Infant Feeding Intervention: • A female counselors are trained to visits mothers of young children • Up to six visits to deliver nutrition messages with help of a picture book

9. Recognizing and feeding a sick baby • A sick baby may present with the following danger signs; • feeling cold, • fever, • weakness and sleepy , • abnormal sleeping, • crying for long times, • High pitched cry, • fast breathing, • difficulties in breathing, • Jaundice, • Irritability and refusing to feed. • Visit you nearest health facility if you see any of these danger signs • Feeding a sick baby • When a baby is sick feeding becomes difficult; she/he may not eat at times and may even fail to breast feed; • The mother should express breast milk and give it to the baby. • (To express you need a clean cup, wash hands and then press your two fingers around the dark part of the breast where there are milk storage tanks, the milk will flow freely • Using a smaller cup, feed the baby regularly, in small amounts, until when the baby is able to breast feed. • Breast feed the child frequently and provide small nutritious feeds with other nutritious fluids like fruit juice, yoghurt and milk; Picture 6 Picture 7

10. To prepare small dried fish (omena) • Take small fish, wash, dry and roast them properly • Allow to cool then pound in a mortar and sieve • Add a table spoon to the porridge; allow it to boil for 5-minutes. • Cool and feed the baby • Keep the rest in a clean closed container for future use • To prepare meat • Cut meat in small parts cook till tender • Choose a boneless piece put on a plate to cool then pound in a mortar until it is smooth • Add it to porridge allow it to boil for 5-minutes. • Cool and feed the baby (you can also prepare liver in the same way remember to remove the skin from the liver) • To prepare groundnut powder • Crush nuts pound in a mortal and sieve you can add this to porridge • To prepare vegetables • Wash the leaves, chop them and cook as normal, do not over cook….. Picture 4 Picture 5

11. Home visiting in Michinji (Malawi) Randomized Controlled Trial showed improvement in: • Mother’s knowledge on nutrition • Diet variety • Exclusive breastfeeding • Child’s height

12. Idea taken up in Western Kenya • Evidence Action • Chlorine dispensers for water treatment

13. Idea taken up in Western Kenya • Promoter in the community takes care of chlorine dispenser • Promoter could be trained to deliver nutrition messages • Variation: a random group will deliver the information to mother, another random group to mother + father

14. Home visiting not a panacea • It depends on the effort of the promoter • Quite time consuming • Might not be the best approach to change widely followed norms

15. Women’s groups • Women’s groups have worked well in Nepal and India but they have been done for birth preparedness • Might allow for stronger collective action to change widely followed norms • But might not have high take up in the community • Not all women might receive information/advice

16. A study that needs to be done: • Home visiting • Women’s groups • Which one does better? And for whom?

17. Health insurance • Route to effective and responsive integrated health system • % population with health insurance is increasing very rapidly in China, Thailand, Colombia, India, Ghana

18. China. Population coverage by the three health insurance schemes, 2003–2011. Meng Q, Xu L (2014) Monitoring and Evaluating Progress towards Universal Health Coverage in China. PLoS Med 11(9): e1001694. doi:10.1371/journal.pmed.1001694 http://127.0.0.1:8081/ploscollections/article?id=info:doi/10.1371/journal.pmed.1001694

19. Insurance based system Zero fee system Money follows the facility Where are they going to go? Facility gets the some money, no matter how many patients they have • Money follows the patient • Patient is empowered • Facility is interested in having more patients: more patients, more money

20. Colombian experience • One of the largest reforms. Implemented this system • Moreover, health facility receives the same amount of money per patient, no matter how expensive the patient is • Large increases in preventive care, curative care visits, and decrease in health expenditure

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