CONTEXT

1. BUILDING SUSTAINABILITY FROMTHE BASEBuilding a Bottom-up Approach to Health in a Hierarchical SystemThe LCCN/GHM PartnershipDavid M. Thompson, MD MPH

2. 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

3. 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

4. LCCN HEALTH SERVICES • First missionary, 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

5. PARADOX The Church & Health Services • Church grew over 100 year period to 2 million members • Once impressive church health service almost disappeared

6. 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

7. 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

8. SOLVING THE DISEQUILIBRIUM COMMUNITIES INDIVIDUALS NEAR FAR POOR RICH INSTITUTIONAL CENTERS Tertiary Secondary Primary Communty-Based

9. BUILDING SUSTAINABILITY FROMTHE BASE

10. IN THIS CONTEXT • Sustainability, What does it mean? • Base: • What is it? • Where is it? • What is its makeup?

11. 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

12. 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

13. 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%

14. Changes in Health Indicators (Jamkhed1971-2006) IMPACT * = data collected

15. CBPHC Program Principles • Service as a witness rather than a tool. • Sustainability through community engagement, empowerment & ownership. • Self sufficiency • Equity • Holism • Interdependency

16. THE PROCESS/STORY • Preparatory team visits 2006 & 2007 • PHC training session 2009 • Visits to Chanrai Foundation PHC project • Visit to SCMS Léré, Chad • Agreement between GHM & LCCN Health Board  Memo of Understanding 2009. • GHM leadership team visits Jamkhed Comprehensive Rural Health Project Jan ‘10

17. PROJECT PLANNING 2010Using 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

18. 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

19. Sustainability* • Sustainability has 3 aspects that can & 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

20. 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

21. 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

22. The SEED-SCALE* Criteria For Assessing Results • Equity • Sustainability • Holism • Interdependence • Iteration

23. 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

24. RESOURCES • Interview with Dr Halfdan Mahler: http://www.who.int/bulletin/volumes/86/10/08-041008/en/index.html • Bangladesh Rural Advancement Committee: http://www.brac.net/index.php