Plan Indonesia

13 PAPERS AUTHORED BY PLAN’S FIELD STAFF
ACCEPTED FOR ORAL AND POSTER PRESENTATION AT THE
2010 ANNUAL MEETING OF THE AMERICAN PUBLIC HEALTH ASSOCIATION
(DENVER, COLORADO, USA, NOVEMBER 6-10, 2010)

Contact person:
Luis Tam, Director of the Technical Unit, Plan USA, luis.tam@planusa.org

7 PAPERS ACCEPTED FOR ORAL PRESENTATION

Kenya: Innovative community organizations improve the survival of rural children
Njoroge Kamau, Plan Kenya

BACKGROUND. In rural areas of Kenya, high childhood mortality due to malaria, diarrhea and pneumonia is still commonplace. THE PROJECT. Since 2004 and for 5 years, Plan International, a child-centered humanitarian organization,has implemented a USAID-funded Child Survival project in the Kilifi district (tot pop 260,000) of the Coast Region. This project, a partnership with the Ministry of Health and non-governmental organizations (NGOs), aimed to sustainably reduce the morbidity and mortality of under-five children. One major project strategy was to link community caretakers with the formal health system (either government or NGO) through the Care Group which brings together 10-15 volunteer health contacts, each representing a homestead. Health contacts select one among themselves who meets agreed criteria as community health worker (CHW). The CHW is trained on community Integrated Management of Childhood Illnesses. The role of a Care Group is to share and discuss health information with their households as well as to mobilize their household for health action including utilization of health services. RESULTS. The project helped organize 1400 care groups which have achieved: immunization coverage has risen by 15% (62%-77%); skilled birth delivery by 23% (13%-35%); bednet use rose from 21% to 77% and the proportion of underweight children has fallen from 27% to 14%. The number of Lives Saved using the USAID Child Survival calculator is estimated to be at least 780. CONCLUSIONS. Based on this project, the Ministry of Health has adopted a variant of the Care Group in its Essential Package for Health Services.

Senegal: Successful task shifting for the implementation of community IMCI – The community health educator
Moussa Sarr, Health Adviser, Plan International, Dakar, Senegal

BACKGROUND. Despite its high child mortality, the implementation of the community IMCI approach in Senegal had no significant difference in the coverage of services partly due to the absence of front-line health workers THE SOLUTION. Plan International, a child-centered humanitarian organization, has piloted a new type of front-line health worker, called the community health educator (CHE), since 1998. A CHE has 10 years of education and previous working experience in community development to be a conduit between the government health facilities and communities. CHEs are private providers and associate into local NGOs to negotiate the delivery of a community-based package of activities with Plan International and the local government. Each CHE has a monthly allowance of about $ 200 U.S, paid by Plan International, and covers an area of about 40 villages. THE RESULTS. Currently, Plan International supports 120 CHE’s covering a total of 1.5 million people. CHE’s have been instrumental in (a) improving the completeness and timeliness in the reporting of community volunteers. (b) increasing the use of health services by 75% to 225% higher than populations not covered by them in the same district. (c) supporting community volunteers to follow the government standards for community IMCI, including patient referral and drug management and (d) helping to bridge the social gap between communities and the government. NEXT STEPS. Today, outside of financial support and monitoring, the management of the CHE’s is made by communities and their local governments including the funding of the CHE’s in their budgets.

Togo: Reinforcing community capacity to protect the lives of children and theirs mothers
Pabanam N’zonou, MD, ME, Plan Togo, Health Advisor, 96 Boulevard Jean Paul II, Tokoin Wuiti, Lome, pabanam.nzonou@plan-international.org

BACKGROUND. In Togo, the under-five mortality rate is 123/1000 mainly due to malaria, diarrhea and respiratory diseases. Communities seldom use health facilities for their health problems. Therefore, a community-based Integrated Management of Childhood Illness (IMCI) program is an opportunity for the reduction of child mortality. THE PROJECT. Since 2008, Plan International, a child-centered humanitarian organization is implementing a three-year community IMCI project in partnership with the Ministry of the Health and a local NGO (SOS Vita) in East Mono district (tot pop 90,000). Baseline studies showed that the practice of the WHO-supported 17 IMCI healthy behaviors was very low. The project activities are: identification, training and equipment with working kits for 310 community health workers; training of 34 health professionals and 6 staff of the local NGO; training of 85 health centers’ management team members; training and sensitization of 53 health committees; production of communication tools for community volunteers to promote the 17 key behaviors. RESULTS: At the project’s mid-term review (October 2009), all community volunteers have been trained in the promotion of 8 of the 17 IMCI practices. A partnership has been developed between public heath service providers, the local NGO and communities in the 52 district communities. As a result, the percent of under-five children using health services has increased by 10% in the first project year, which is beyond the project’s expectations. NEXT STEPS. The implementation of the project is underway and in the Denver APHA meeting, the authors will have outcome results to report.

Cameroon – Successful youth participation in community-based malaria control
Ephraim Toh, SPH, MPH, MD; Takou Mayeul, Plan Cameroon, Tsuma Laban, Luis Tam, Plan international, USA

BACKGROUND. In Cameroon, at least two million cases of malaria are reported yearly from health facilities. THE PROJECT. Since 2005, Plan International, a child-centered humanitarian organization, and the Ministry of Health, are implementing a 3-year malaria control project in Akonolinga health district targeting 23,667 children under five and pregnant women. Project strategies include free distribution of long lasting insecticide treated nets, environmental cleanliness and intermittent preventive therapy (IPT) of malaria in pregnancy. The core of the behavior change communication activities are community education and mobilization by Plan-supported youth groups. Youth groups implement: (a) Plays, sketches, theaters and health talks on malaria control during public ceremonies; (b) conduct regular home visits to ensure effective use of bed nets and promote IPT; (c) organize cleanup campaigns to drain stagnant water, fill up pot holes and clear bushes; (d) organize exchange visits to learn from good performing youth groups on malaria control; (d) implement the free distribution of long lasting insecticide treated nets to under-5 children and pregnant women. RESULTS. As compared with the 2005 baseline results, the project has been responsible in 2009 for: (a) increasing the IPT coverage from 60% to 81%; (b) for increasing the percent of under-five children sleeping under a bednet from 5% to 84%, and (c) increasing the percent of pregnant women sleeping under a bednet, from 13% to 85%. CONCLUSIONS. (a) Youth and community participation can effectively control malaria; (b) Bed net use could be enhanced by frequent home visits.

Hygiene Promotion through Local Games in Indonesia: A Friendly and Fun Tool for Children
M. Afrianto Kurniawan, Plan Indonesia, WES Facilitator. Dompu Program Unit.

BACKGROUND. Dompu is a remote district in east Indonesia, populated by 209,000 people. One of the biggest problems for school children in Dompu is the diarrhea. More the 4000 diarrhea cases per year happened to children in school ages in 2007. Plan International, a child-centered humanitarian organization, Plan Indonesia has been working in Dompu since 1997. Beginning in March 2009, Plan international conducted a hygiene promotion program among 3,000 students in 18 primary schools. An edu-tainment strategy was chosen, through the application of life-size versions of the popular “snakes and ladders” board game, with a size of 25 square meters and with key hygiene behavior massages inserted into the games. 36 teachers were trained on the use of the games. RESULTS. After 8 months of implementation, 77% of children have played the games. The number of children who knew the causes of diarrhea problem increased from 40% to 74.29%. The percentage of student who washed their hands with soap before eating and after defecation reached 95,6%; and 87.5% of children defecated in latrines. The direct cost of the activity was USD 5,300. CONCLUSION. Simple local games are an effective hygiene education tool for school-children. Primary schools in three additional districts have adopted the games and introduced it to more children.

Cambodia: Successful and Cost-effective Rural School Water and Sanitation Program
Syvibola Oun, Water and Environmental Sanitation Advisor, Program Support Department, Plan Cambodia, Phnom Penh, Cambodia

BACKGROUND. Currently, 34.8 percent of primary and secondary schools in rural Cambodia do not have water and 22.4 percent do not have latrines. Few schools have hand washing facilities and the existing latrines are either not functioning or not properly used. Apart from an increased burden of diarrheal and skin diseases, this situation especially contributes to the high drop out rate of girls when their menstruation begins (as schools lack sanitation facilities to ensure privacy). THE PROJECT. Since 2004, Plan International, a child-centered humanitarian organization, has improved water and sanitation services in 88 rural primary and secondary schools in the provinces of Kampong Cham and Siem Reap, benefiting 26,400 students (including 13,728 girls). Clean water was provided through ceramic water filters, two filters per classroom. Separate toilet facilities were built for boys and girls, both accessible for disabled students. Plan Cambodia also trained students, teachers and a community committee on the operation and maintenance of these facilities. RESULTS. 1,877 ceramic water filters were distributed and latrines were built in the 88 participating schools. Teachers and Plan Cambodia staff have reported less absenteeism and less sickness among students. Latrine construction costs are $2400/school and water supply costs are $1700/school, plus costs of the training and education activities. The total cost for 88 schools was $420,864. CONSEQUENCES. Students were less sick and less absent from school due to improved water and sanitation facilities. The government of Cambodia is analyzing the methods and results of this project for potential scale-up in the country.

Vietnam – Improving water and sanitation in rural communities through capacity building and community choices
Ho Ha, Water and Sanitation Project Manager, Plan International, Hanoi, Vietnam

BACKGROUND. The Quang Ngai Province is among the poorest in Vietnam. Its population is highly vulnerable to water-borne infections due to poor sanitation and hygiene practices and water scarcity. THE PROJECT. Since 2006, Plan International, a child-centered humanitarian organization has been implementing a 4-year water, sanitation and hygiene (WASH) project in 16 communes of this province (total pop 115,000). The project’s components include (a) capacity building of project implementers; (b) awareness and education activities to families to make informed choices on the project-supported WASH improvements to be adoand to co-finance the financial contributions of the project; (c) provision of small grants and technical assistance to families willing to make WASH improvements. Project implementers are grassroots organizations such as Women’s Unions; government authorities at Provincial, District and Commune levels. RESULTS. (1) The Project has reached 9,475 households who made 11,802 WASH improvements with 10,264 small grants awarded. The number of improvements is larger than the grants, hence a leverage motivated by project. (2) The project stimulated demand for loans from commercial banks in addition to small grants. 9% of the households have taken loans. (3) Awareness of partners and communities on the importance of WASH activities increased through training and capacity building activities. (4) The women’s burden of labor has declined due to increased access to WASH facilities. NEXT STEPS. During the next phase of the project (2010-2011), Plan International will consolidate the lessons learnt and link them to the upcoming National Target Program for Rural Clean Water Supply and Sanitation.

6 PAPERS ACCEPTED FOR POSTER PRESENTATION

Pakistan – Successful screening and management of visual refractive errors in rural schools
Irfan Ahmed, MD MPH , Health Department, Plan Pakistan, Islamabad, Pakistan

BACKGROUND: Visual refractive errors among school-aged children limit their learning abilities, education and their confidence. Plan International, a child-centered humanitarian organization, implemented a pilot School Eye Health Programme in 2005 in 27 rural primary and elementary schools. A 3% prevalence rate of refractive error was found. THE INITIATIVE: The pilot project was scaled in 2006 to cover all schools in the sub-district of Chakwal (tot pop 550,000). In close collaboration with the government and a local NGO, training modules and examination/screening kits were developed and provided to schoolteachers. A schoolteacher accompanied the students found positive at the screening to a referral hospital. An ophthalmologist re-examined all referred girls and boys and those having refractive error were provided free glasses. Out-of-school children were also screened through trained government field workers. RESULTS: During 2006-8, 131, 703 children were screened by school-teachers and 12,555 were referred to hospital. 7,631 children were provided free glasses of their own choice. The prevalence of refractive error was 5.79 % and it was higher in girls than boys. Schoolteachers’ participation in the eye-screening program helped them understand that its correction enhanced the children’s school performance. Children having glasses were more confident; few drop outs of children corrected for refractive error were observed and children began participating in extra-curricular activities. CONCLUSIONS. Annual school eye screening should be done in all schools, given its cost-effectiveness. This program is being replicated in the Vehari district with the support of the NGO Sight Saver.

Honduras – Clean and low-consumption stoves improve health of children and families
Dax Martínez, MBA, Honduras Country Office – Plan International, Colonia Palmira, Edificio CIICSA, 4to Nivel, Tegucigalpa, Honduras.

BACKGROUND. Food cooking in rural homes of Honduras involves a high consumption of firewood due to the use of traditional stoves; also this brings high concentrations of smoke into the house, dirty kitchens and the first cause of respiratory illness in family members. The search for firewood is done over long distances off the community, mainly because the forest is disappearing for the increasingly exhaustion. Schools dropout are directly related to this activity because children are mainly responsible for searching and bringing the wood. THE PROJECT. Since 2008, Plan International, a child-centered humanitarian organization, has helped build improved stoves in 4000 households in 6 districts of the country. These stoves consume less wood and produce less smoke than the traditional stoves in rural homes. Their construction was accompanied with practical training on its operation and maintenance and on health, hygiene and cleanliness of the dwellings. RESULTS. Based on reports from local health facilities and community volunteers, these populations have experienced a noticeable fall in the rates of acute respiratory diseases among children and their mothers, who are the most exposed to the stoves’ smoke. Moreover, noticeable positive changes are observed in personal hygiene, cleanliness of the houses and cooking practices. CONCLUSIONS. With the improved stoves, rural families in Honduras enjoy better health and cleanliness, and also have more time to devote to productive activities, plus a reduction in forest degradation.

El Salvador: Youth group helps improve reproductive health and prevent HIV infection among 4,000 adolescents
Anabell Amaya. National Advisor on Health, Plan El Salvador; Margarita Alvarado, Plan El Salvador

BACKGROUND. Youth from poor populations in El Salvador are exposed to early sexual initiation, early pregnancy and a high risk of HIV infection. THE PROJECT. In 2005 and for four years, Plan International, a child-centered humanitarian organization, helped in the development of a youth organization in the department of Chalatenango to improve reproductive health and prevent HIV infection among adolescents living in 28 high-risk municipalities. Project strategies included awareness campaigns (e.g. youth peer educators), community activities (e.g. youth clubs), and facilitating the access of youth to preventive and integral healthcare services. RESULTS. One the most successful youth groups was based in the town of Citalá, Chalatenango, and comprised 10 men and 6 women between 13 and 26 years old. In its three years of participation in the project, this group was responsible for educating 4,000 adolescents, distributing almost 11,000 condoms, as well to raise awareness among 2,572 truck drivers frequenting the border between El Salvador and Honduras. Group members have delivered project services at odd hours. One of their largest challenges has been the discrimination resulting from the sexual orientation of a number of the members. This discrimination was felt not only from institutions like the mayor’s office and schools, but also from some of the local health establishment representatives. CONCLUSIONS. This experience shows the impact of external assistance to a relevant and motivated local partner. Today the network is very strong and highly recognized by the other networks, social organizations and governmental institutions.

Bangladesh – Successful education on parenting skills for adolescents.
Muhammad Munir Hussain, MBBS MDS 1, Selina Amin, MBBS MPH 2, Hasan Ali3, MSS MBA, Tahmina Mirza, MBBS, MPH. Plan Bangladesh, House # CWN(B) 14, Road #35, Gulshan-2, Dhaka 1212, Bangladesh

BACKGROUND. In Bangladesh, adolescents are living with strong family bondage and dependent on their parents for decisions which could affect their life and development, e.g. early marriage, early pregnancy and services for safe motherhood. As a result, a better understanding of the needs of adolescents by the parents and an improved adolescent-parent communication is very important. THE PROJECT. Since 2008, Plan International, a child-centered humanitarian organization, has initiated a four-year ‘Adolescent Parenting’ intervention for the parents of adolescents in 510 communities with a total of 818,000 inhabitants. Interested, motivated parents with leadership skills were selected as Peer Educators for each group of fifty parents living in same geographical area. An unique training manual on ‘Adolescent Parenting’ was used, with topics including understanding adolescence, adolescent changes and its manifestations in behavior, peer influence on adolescents and socio-cultural factors. Peer educators conveyed the knowledge from the training to their peer parents in four to five informal sessions. Sessions were usually conducted at informal settings e.g. tea stall, cloth washing spot at pond side, or at neighbor’s houses with convenient timing for all. RESULTS. About 6000 peer educators have been trained (3500 women). Participating parents noticed that after the training, they were better equipped to discuss and to orient their adolescents on sensitive topics, helping to an improved adolescent-parent relationship and better health and social behaviours. NEXT STEPS. In the next two years, Plan International plans to scale up this intervention among new populations and phasing out from the initial area of application.

Community-managed Clinics: Empowering the community to improve their access to primary health care services in Bangladesh
Israt Nayer, MBBS, MPH 1, Saqui Khandoker, MD 2, Edward Thomas Espey 3, Selina Amin, MBBS, MPH 4, Plan Bangladesh, House # CWN (B) 14, Road #35, Gulshan-2, Dhaka, Bangladesh

BACKGROUND: In 1999, the Government of Bangladesh established Community Clinics (CCs) at village level to provide basic health services. In 2004, the Ministry of Health approved Plan International, a child-centered humanitarian organization, to pilot models of community-based service delivery and governance in 18 rural CCs serving 108,000 people. THE INITIATIVE: Representatives of the local municipalities and of the Ministry of Health signed a Memorandum of Understanding with Plan International. The catchment area and population to be served by each CC was identified and validated through community organizations. For each CC, a Community Clinic Management Group (CCMG) was formed with representation from different sections of the community including women, children and the poor. CCMG were trained on management and resource mobilization and to develop a plan of action to operate the clinics. RESULTS. Community participation in the identification of service needs, clinic’s hours of operation, cost sharing arrangements (e.g. paying salaries of cleaner and guard) has increased the access of the people to basic health and family planning services. Regular monitoring by the CCMG and maintaining the books of accounts ensured transparency and accountability. A client satisfaction survey revealed that 98% of service recipients received the services for which they came and 99% of them were satisfied with the quality of services. 95% reported the clinic was situated at a place and time accessible to them. CONCLUSIONS. CCMGs has been successfully running the CCs with quality services. The Government is considering its replication in 18,000 CCs throughout the country.

Uganda: A Holistic Approach To The Prevention Of Mother To Child Transmission Of HIV
Charles Luwaga MD, MPH; Country Health Advisor Plan Uganda

BACKGROUND: In Uganda, with over 90% of the new infections among children due to mother to child transmission, effective implementation of prevention of maternal to child transmission (PMTCT) is crucial. THE PROJECT. Plan International, a child-centered humanitarian organization, implemented a 4-year comprehensive PMTCT project in the rural Tororo District (tot pop 170,000). The target population was 1,500 HIV positive pregnant mothers and their families. The project objective was to increase the uptake of PMTCT by including ART for the mother, patient care and support, food security and income generation initiatives for the affected families. RESULTS. 20,229 pregnant mothers were tested for HIV of whom 1,535 were positive (7.6%) and 744 clients were put on antiretroviral therapy. Seventy two percent of the HIV positive pregnant women disclosed their HIV sero-status to their husbands; adherence to ART was greater than 95% and the rate of vertical transmission reduced from 30% to 7.0%. Moreover, 25 HIV Post-test clubs were formed and their organizational capacity enhanced; almost 2000 clients in 66 associations participated in income generation initiatives and 32,911 individuals underwent voluntary counselling and testing. HIV-affected families now have a better capacity to meet the transport costs and purchase of medications for opportunistic infections. These successes are attributed to psychosocial support by social workers, the inclusion of ART with volunteers directly observing treatment and the establishment of food and economic security interventions. CONCLUSION: These lessons are also being shared with the government and with other NGOs for potential replication.