Elaine Rossi of JSI and Catherine O

1
Introduction

• Elaine Rossi of JSI and Catherine OBrien of The
  Manoff Group presented the following at the
  Global Health Council Conference, May 2008.
• The PESCE project has had remarkable success in
  community mobilization for health in Djibouti.
• PESCE is funded by USAID and implemented by JSI.
  The Manoff Group is a subcontractor, responsible
  for behavior change communication and community
  mobilization.

2
From Five Villages to a National Policy
Community Mobilization in Djibouti
Dr. Stanislas Nebie, Chief of Party, PESCE,
JSI Dr. Chehem Watta, Senior Advisor, Ministry of
Health, Djibouti Dekha Hadi, Social Mobilization
Assistant, PESCE Catherine OBrien, Senior
Technical Advisor, The Manoff Group Elaine Rossi,
Senior Technical Advisor, JSI

• Expanded Coverage of Essential Health Services
  in Djibouti Project (PECSE)

The authors views expressed in this publication
do not necessarily reflect the views of the US
Agency for International Development or the US
Government.
3
Country Context 2004

• Population 800,000
• Size of US state of Massachusetts
• Life expectancy 46 yrs
• Infant mortality 103 per 1,000 live births
  (2002)
• Under-5 mortality 121 per 1,000 live births
  (2002)
• Maternal mortality 650 per 100,000 live births
  (2002)
• Malnutrition, malaria, TB all pose great risks

4
Health System Context 2004

• Weak infrastructure
• Unreliable health statistics and poor health
  knowledge
• No community mobilization for health!
• MOH health sector reform strategy aims to
  increase access to health care through
  decentralization, prevention, and primary care

5
Poor infrastructure
Poor water source in Gourabouss 2005
As Eyla clinic beds 2005
6
Resource Scarcity
Water struggle in Dorra April 2005
7
PECSE Project

• 20042008
• Expand access to health services
• Rehabilitate health facilities
• Train health care providers
• Establish health management information system
• Mobilize communities
• Focus on rural areas

Sagalou Health committee members, April 2006.
The Health Committee President is seated on the
left.
8
Community Mobilization Challenges

• No community mobilization existed before in the
  health sector
• MOH not receptive to idea
• Health infrastructure in terrible condition
• Nomadic populations refugees
• Difficult physical environment

9
Laying the Groundwork

• Back to Basics
• Not ready for BCC
• Pilot program in 5 sites in 2005
• Very basic community mobilization

PECSE and MOH staff in discussion with Goubetto
community chief in 2005, when negotiating the
establishment of a health committee
10
Community Mobilization Pilot Approach

• Health Post ? Health Committee ? community
  members forging links to improve services
• Community health volunteer is the link between
  community and health post staff

Daley Aff Community volunteers Jan 2006
11
Involving the MOH

• PECSE cultivated excellent relations with MOH,
  UNICEF, WHO, NGOs, and others
• Study tour to Ethiopia and Madagascar
• Consensus on community mobilization emerged after
  study tour
• MOH interested in replicating model

Djibouti health committee members and nurses
during the study tour in Madagascar, 2005
12
Scaling Up

• 5 pilot sites? 23 health posts
• Each post linked to health committee
• Each committee has men and women
• 4 or 5 community volunteers (at least 2 female)
  per community

Gallamo community leader giving working tools to
a volunteer May 2006
13
Training and Supervision

• Training-of-trainer workshops nationwide for
  community health volunteers
• Health education activities
• Joint supervision by MOH and PECSE

Dorra female health volunteer receiving a loud
speaker for community mobilization August 2006
14
Training
Community trainer during Arta health committee
members training May 2006
Work plan development during the Tadjoura
district volunteers training June 2006
15
Supervision
Gourabouss community volunteers during a
supervision session Aug 2006
Randa village volunteers during supervision Sept
2006
16
Mobilization at work

• PECSE carried out MOH priorities
• Emergency immunization campaigns
• Polio in 2005 Health Committees and Volunteers
  proved themselves
• Cholera in 2006 further validation
• Volunteers and committees trained in prevention
  and symptoms
• Volunteers spread messages and identified cases
  for nurses to treat
• Avian influenza preparedness

17
Additional Activities

• MOH requested urban community mobilization work
• Flipchart produced covering 9 health themes for
  nationwide distribution
• Mobile caravan performed skits
• Radio spots

Mobile theater group performing a skit
18
Flip Chart Preparation
Nutrition for a nursing mother
Tadjoura district volunteers and community
members training in flip chart utilization Feb
2006
When to take a child to the health post
19
Infrastructure Rehabilitation
Incinerator now available in the 23 project sites
for medical waste management
Medical waste situation in 2005
Solar pump installation in Assamo
Drilled well in 2008
20
Infrastructure Rehabilitation
Alaili-Dada Clinic
2004
2005
Medeho clinic toilet
21
National Community Mobilization Strategy

• After study tour, MOH formed committee on social
  mobilization for health policy
• PECSE provided framework for policy
• National Policy promulgated in 2006!
• Validated role of Community Health Volunteers and
  Health Committees
• Created new MOH cadre of Health Aides based on
  Ethiopian model

22
A major step forward
Ass-Eyla health committee members showing their
certificates of recognition with pride April 2008
23
Results

• By late 2006 utilization rates rose for prenatal
  care and immunization
• Contributed to positive national results

2002 2006
Infant Mortality (per 1000 live births) 103 67
Under-5 Mortality (per 1000 live births) 121 94
CPR 12 18
The Project social mobilization assistant with
the Gallamo female volunteer s child 2006
24
Results Deliveries
25
Results Antenatal Care
26
Thanks to a great team
Minister of Health and Project COP at Knighthood
Ceremony for COP, May 2008
Community Mobilization Team May 2008