5
Using Existing Platforms to Integrate Services on the Ground
One of the sessions of the workshop looked at how to use existing platforms to set up, implement, and scale integrated or coordinated services in the areas of health, education, nutrition, and social protection. In Bangladesh, for example, the nongovernmental organization BRAC (formerly the Bangladesh Rural Advancement Committee) has developed an integrated childhood development intervention through its Maternal, Neonatal, and Child Health Program that delivers a wide range of services in a very cost-effective way. In Pakistan, the Lady Health Workers Program has combined a nutrition intervention with an early childhood development intervention that has been studied as a model of integrated programs. In New York City, the Mount Sinai Adolescent Health Center provides cost-effective integrated services to a vulnerable population. (Addressing inequality with vulnerable populations is also discussed in Chapter 7.) All of these examples of integrated services coming together on the ground provide lessons for coordinated and integrated approaches elsewhere.
HOLISTIC DEVELOPMENT AND LEARNING IN EARLY CHILDHOOD: INITIAL EXPERIENCES FROM BRAC
BRAC is a very large nongovernmental organization that, through its Maternal, Neonatal, and Child Health Program, serves a population of 25 million rural residents and 7 million urban residents of Bangladesh. As described by Mushtaque Chowdhury, vice chair of BRAC and professor
of population and family health at Columbia University’s Mailman School of Public Health, the program has a five-pronged operational strategy:
- Health workforce development
- Community empowerment
- Service delivery at the community level
- Timely referral of emergency cases
- Linkage with public and private health facilities
BRAC has introduced an integrated early childhood development intervention, based on earlier activities it has undertaken, with the goal of fostering “children’s holistic development by creating a joyful and child-friendly learning environment at home, center, school, and community,” said Chowdhury. Developed in collaboration with Columbia University and BRAC University, the program includes a wide variety of home-based and center-based care and learning (see Figure 5-1). Before age 3, early childhood development is integrated with nutrition and health. After age 3, the intervention is coordinated with the education program. The target population is pregnant women and lactating mothers, children up to 8
FIGURE 5-1 BRAC has adopted an integrated early childhood development model that includes both health and education in homes and centers.
NOTE: SBK = Shishu Bikash Kendro (child development center in Bangladesh).
SOURCE: Chowdhury, 2015.
years of age, and parents and other caregivers. In a pilot phase from 2013 through 2015, the intervention reached about 45,000 people, with a recent expansion projected to reach nearly 200,000 people by the end of 2016.
From January through December 2014, more than 2,000 pregnant women and lactating mothers were counseled on maternal health, nutrition, early childhood development, newborn care, breastfeeding, and massage and bathing technique. About 90 percent of the children in the program have achieved age-appropriate gross motor development, Chowdhury reported. More than 75 percent of the children in the program achieved age-appropriate cognitive development, along with reported findings of increased confidence, play, and handwashing.
The annual costs in the pilot program, including BRAC’s contribution and a community contribution, have been about $40 for children through age 3 and US$120 for children ages 3 to 5. Furthermore, these costs have decreased—to US$30 and US$102, respectively—in the expanded program due to economies of scale.
Historically, BRAC has emphasized integrated approaches to early childhood development, Chowdhury observed. But he noted that scaling up integrated programs can be difficult when financing comes from individual sectors; doing so requires planning in terms of logistics, training, and evaluation. Another complication is coordinating between an early childhood health program and the education system as children get older, because these programs are typically separate.
Chowdhury drew several conclusions from BRAC’s experiences. First, stakeholders need to be more aware of the importance of early childhood development, he said. Starting more experiments in different settings could help build this awareness. Early experience with the pilot program has indicated that the program should be scaled up to reach as many children as possible, he observed. In addition, monitoring tools with easily tractable indicators and research methods to measure the effects of interventions would help make the case for much wider application of these approaches.
In response to a question about whether specially trained members of the community could be used to provide the services that community health workers provide, Chowdhury pointed out that efforts to use community members have a tendency to fade. Community members need an incentive to continue to provide services. Linkages to the health system also are important, he said. “What has happened in the past is that the nongovernmental organizations have trained community health workers, but they have been left on their own without really connecting with anything.” The close relationship between BRAC and health workers who are part of the government health system has helped build the program.
Pakistan is an extremely diverse country, which can complicate the delivery of services to families and children. As Zulfiqar Bhutta, Robert Harding Inaugural Chair in Global Child Health at the Hospital for Sick Children in Toronto and founding director of the Centre of Excellence in Women and Child Health at Aga Khan University, noted, “There are parts of the country where living standards may be comparable to what you have in the West, and there are others where conditions are comparable to sub-Saharan Africa.” The distribution of resources is correlated with health services availability and access. In some parts of the country, only 10 to 20 percent of the population has a skilled attendant present for births; in areas with higher human development indices, access to appropriate care for children with respiratory infections, particularly pneumonia, is greater than elsewhere.
The Lady Health Workers Program was begun by the public sector in 1994 and now supports more than 100,000 lady health workers, distributed largely in rural populations. (Physicians in Pakistan, in contrast, are concentrated in urban populations.) Lady health workers have a largely preventive, promotive, and supportive role, explained Bhutta. They serve primarily to promote family planning, provide antenatal care provision and some commodities, conduct health education, and make referrals for very ill children and women. They do not, in general, provide curative services beyond oral rehydration and simplified antibiotic therapy for respiratory infections.
The Lady Health Workers Program was designed to enhance the quality of the nutrition services provided by the public sector. The program also has been used to strengthen the provision of commodities and education, particularly in the early part of infancy. In addition, the program has incorporated an adaptation of the Care for Child Development Package developed by UNICEF and the WHO. With support from early childhood development facilitators, lady health workers provide mothers with education about such factors as interaction, responsiveness, nutrition, parenting, and the reduction of stress, both through individual counseling and monthly group meetings.
In a randomized trial, Bhutta and Aisha Yousafzai, the director of research in the Department of Pediatrics and Child Health at Aga Khan University, along with a group of colleagues, studied the effects of the program on about 1,200 children through 24 months of age. Four separate groups received the early childhood development intervention, the enhanced nutrition intervention, both interventions, or neither intervention. The key finding of the study, said Bhutta, was a “significant and
TABLE 5-1 Effect Sizes of Interventions on Development
| ECD and Enhanced Nutrition Group | ECD Group | Enhanced Nutrition Group | |
| Cognition | 0.5 | 0.6 | 0.2 |
| Language | 0.6 | 0.7 | 0.4 |
| Motor | 0.4 | 0.5 | 0.2 |
NOTE: ECD = early childhood development.
SOURCE: Yousafzai et al., 2014.
notable impact on development.” The children whose mothers received the early childhood development intervention scored significantly higher on measures of cognition, language, and motor behavior, though there was no effect on social and emotional measures (see Table 5-1). These children also scored better than those who only received enhanced exposure to information on nutrition. However, adding education in early childhood development to enhanced nutrition information did not produce an additional benefit in terms of developmental outcomes. “That was a bit of a surprise,” said Bhutta, “because we expected intuitively that that group would do the best, but it did not in terms of its overall impact.” Also, integrated delivery of particular services proved more effective than the enhanced nutrition intervention but no more effective than the early childhood development intervention, although all three groups did much better than the control cluster.
The families were very enthusiastic about the program, Bhutta reported. They liked their interactions with the lady health workers, particularly with the combined interventions and the early childhood development intervention. The interventions did not have a clear impact on dietary diversity, though diets did improve over time. But the groups receiving the interventions did improve compared with the controls, largely, said Bhutta, “because this was a rural and relatively food-insecure population where no additional food supplements were provided.” In addition, the interventions did not have an impact on stunting of growth in children.
Bhutta drew several lessons from the study. First, supervision from the facilitators and experiential learning made a difference for the lady health workers. Introducing new practices into an existing system “is not a simple thing of just walking through the door to say ‘Do this.’ You have to negotiate with both the program people and also the health worker supervisors.”
Any new program needs to acknowledge what health workers know,
and facilitate an understanding of linkages between new and existing messages, said Bhutta. In addition, some factors negatively influenced the performance of the health workers, such as the number of households they were serving and the number of tasks they had to perform.
Sometimes the availability of community health workers serves as an excuse for not doing things in the rest of the health system. But they have specific responsibilities, and if something is added to their responsibilities, something else needs to be removed. “When the government pulls health workers off and puts them in the polio program for 30 percent of their time, that is when things go south.”
Another lesson is that quality matters. On-the-job coaching, supportive supervision, and master trainers were among the factors that improved quality over time.
Mixed methods of delivery were important, Bhutta said. Lady health workers normally do one-on-one counseling, but the group counseling undertaken as part of the project also was popular and effective in terms of reaching people. Effective group meetings were marked by caregivers and children attending together, a participatory approach to information sharing, opportunities to practice activities and receive feedback, a diversity of topics with repetition of selected core messages, and smaller groups. Home visits also were effective in terms of both problem solving and observation of behavior.
Integrated counseling could be promoted through curriculum development and training that highlights the links between new and existing messages; the ability of lady health workers to answer questions on health, feeding, and care; and the promotion of responsive care using play, communication, feeding, and teachable moments. The augmented program involved not just health but input from such areas as promoting food security, gender empowerment, issues related to education, and environmental issues. “The project is a huge success in underscoring the feasibility of doing this and now needs to move from a proof of principle of actually doing this at this level to the next level of trying an approach that brings in those additional sectors.” That could lead to practical implementation at the district level, Bhutta said. “Whether that is done in an integrated framework or in a combined framework is completely open to question. At a district level, it could probably have more than one model of operation.”
Bhutta raised the issue of counterfactuals: Are lady health workers an appropriate way to deliver an early childhood development intervention? The first issue to examine involves time commitments. Lady health workers are public-sector primary care providers whose principal charge is to reduce mortality and provide child survival interventions. Additional interventions inevitably have an effect on the time attributed to their prin-
cipal tasks. In some cases, lady health workers objected to the increased levels of supervision and responsibilities, and some left the program, but this problem was not severe.
The interventions delivered in the study did not reduce mortality. “If anything, there were some counterintuitive trends which suggest that as we scale up these programs we have to make sure that the core functions of these public-sector workers, which are largely in high-mortality areas to make sure that life-saving interventions are delivered, are not compromised,” Bhutta said. “I am pretty confident they would not be, but we need to prove that and show that to the program people as these programs are scaled up.” Costs are another issue, because the program required extra people and support.
To address some of these issues, Bhutta emphasized the need to “think out of the box and out of the health sector.” For example, the interventions did not have an effect on nutrition because the health workers had no link with nutrition-sensitive sectors, he said. “They could not do anything for food insecurity; they could not do anything for agriculture or social protection, because they are not linked to those programs.” One option would be for health workers and nonhealth workers to work in tandem. Another option would be to find a way to bring multisectoral or intersectoral workers together at the district level.
Bhutta also pointed out that global reviews have been conducted showing that community health worker programs generally have not been able to integrate early child development interventions at scale. The health sector always has limitations, including lack of contact between health workers and people in other sectors. But early childhood development goes beyond health and has to involve these other sectors. “We need to be a lot more imaginative in terms of how to use these community workers—and, increasingly, a wide range of players, not just health workers—and link them with some of the objective outcomes that donors, funders, and policy makers are interested in. That means that we have to go outside of the health worker platform.”
In response to several questions about the intervention, Bhutta pointed to some of the other limitations on scaling up. For the facilitators to be included in the Lady Health Workers Program, they would need to be created from the existing staff or be added from outside the program. Another issue raised in the discussion was the value that future evaluations could provide if they determined whether the program increases school readiness, school involvement, and educational performance.
THE MOUNT SINAI ADOLESCENT HEALTH CENTER
The Mount Sinai Adolescent Health Center serves vulnerable populations, is integrated at many levels, and is a relatively low-cost program by U.S. standards. It is the kind of program whose principles could be widely replicated, said the director of the program, Angela Diaz, who is the Jean C. and James W. Crystal Professor in Adolescent Health and professor of pediatrics and preventive medicine at the Icahn School of Medicine.
The center annually serves more than 11,000 young people ages 10 to 24, 70 percent of whom do not have health insurance. Of this population, 98 percent are poor, and 92 percent are youth of color—mostly African American and Latino. But they have a tremendous diversity of backgrounds, with some from loving homes and others homeless, Diaz said.
The center provides adolescent-friendly services, which Diaz described as “taking the adolescent perspective. . . . What is it that they want, what is it that they need, what is going to help them come and avail themselves of the services?” To reduce stigma, it is called a teen center rather than a family planning clinic, HIV clinic, or substance abuse clinic. The program is accessible geographically and financially so it is easy for teenagers to use. The staff try to build relationships with the adolescents who come to the program so they feel loved, respected, and connected. “Some youth say this is the first time that they feel safe.”
At the programmatic level, the program is integrated with clinical services, training, research, advocacy, and policy. At the health level, it is part of a continuum of wellness promotion, health promotion, prevention, and risk reduction. It provides primary health care, sexual and reproductive health care, mental health care and psychosocial support, dental care, optical care, special services (including services for the lesbian, gay, bisexual, transgender, and questioning community, HIV, substance abuse, victims of interpersonal violence, and teen parents), and medical-legal services (see Figure 5-2). “It is taking care of the entire person, not just pieces of the person.”
Some young people need additional support, including those who are gay, lesbian, and transgender; who abuse substances; who are HIV positive; who are victims of violence, incest, sexual abuse, rape, or domestic violence; or who are parents. For teen parents, the center sees the parents and their children on the same day and provides services to prevent another pregnancy and ensure that the child is developing properly. It works with schools, parks, arcades, nightclubs, and other community institutions to engage young people and provide support to them. It also trains young people to be leaders and work with other youth both in the adolescent health center and through New York City schools.
A number of research projects have focused on the center, including projects on abuse disclosure in primary care settings, contraception, and
FIGURE 5-2 The integrated program at the Mount Sinai Adolescent Health Center encompasses a wide variety of services.
NOTE: AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; LGBT = lesbian, gay, bisexual, and transgender; STI = sexually transmitted infection.
SOURCE: Diaz, 2015.
sexually transmitted diseases. A third-party evaluation of the center’s work was ongoing at the time of the workshop.
The program is very cost-effective, according to Diaz, spending less than $1,000 per youth per year, which is less than the cost of a typical emergency room visit. Participants in the program have a much lower teen pregnancy rate than other youth in New York City, and sexually transmitted infections like chlamydia receive treatment to prevent their spread. Participants in the program have fewer emergency room visits, and 90 percent stay in school, which is a much higher percentage than for African-American and Latino youths in general.
The program is very interdisciplinary, involving health educators, social workers, psychologists, nutritionists, and physicians all working together. Furthermore, a new initiative is bringing together health,
education, jobs, and housing by training and placing community health workers in public housing and training youth also to become community workers. “We are just at the beginning of that, but we think it is very important.” The idea is to follow children as they age and interact with different systems to ensure they receive the services they need.
A recurrent issue with the program has been financing. “We don’t have a sustainable financing mechanism right now,” Diaz said. The program needs to raise $10 million each year, “and we begin at zero every year. We do it, and we raise the money. We don’t charge the youth; everything is free. We don’t exchange money at all. We buy their medication, we give them transportation. But it takes a lot of work. Basically, I am trained as a physician, but I spend my time raising money to be able to see these youth.” The evaluation now being done is expected to produce data that could help show policy makers how cost-effective the program is, not just in terms of human lives saved but money saved on health care, education, and jobs “because these young people stay in school and can be trained instead of putting them in prisons.” Research results have shown that the program is effective, “but people are not going to be able to do it unless they know how to sustain it.”
Diaz closed with several recommendations drawn from her experiences at the center. It is important to integrate as many elements as possible within one clinical service, including primary health care, sexual and reproductive health care, and behavioral and mental health care. Adolescents cannot be expected to understand how to navigate health care silos, which requires removing barriers between different aspects of services. She also said that research is needed on the best ways to get adolescents to initiate and continue care, the comparative effectiveness of these approaches, successful ways of integrating public health and primary care interventions, and the most effective division of responsibility between public health and primary care to reduce significant risks among adolescents. Finally, she called for a national policy on youth that includes the development and financing of services tailored to meet the needs of young people.
