Strengthening Strengthening Routine as a Routine as a Motor for other Motor for other InterventionsInterventions

A report from A report from CCôôte d’Ivoirete d’Ivoire

Partners for Measles Advocacy 8Partners for Measles Advocacy 8thth Annual Meeting Annual Meeting Washington DC, 23 – 24 September 2008Washington DC, 23 – 24 September 2008

Maya van den Ent, PharmD, MPH, UNICEFMaya van den Ent, PharmD, MPH, UNICEF Alphonse Toko, MD, UNICEFAlphonse Toko, MD, UNICEFEdward Hoekstra, MD, MSc, UNICEFEdward Hoekstra, MD, MSc, UNICEF Paul Basikila, MD, UNICEFPaul Basikila, MD, UNICEFRownak Khan, MD MPH, UNICEFRownak Khan, MD MPH, UNICEF Epa Kouakou, MD, UNICEFEpa Kouakou, MD, UNICEF

UNICEF

Outline

Country situation of Cote d’Ivoire

Measles campaign micro-planning

Routine immunization

Integration of High Impact Interventions with RI

Can measles campaign strengthen Can measles campaign strengthen

routine immunization & health systems?routine immunization & health systems?

UNICEF

Cote d’Ivoire - Abidjan

UNICEF

Cote d’Ivoire

Zones under control of impartial forces

ABIDJAN

TIASSALEAGBOVILLE

BANGOLO

BEOUMIBIANKOUMA

BOUAFLE

BOUAKE

BOUNA

BOUNDIALI

DABAKALA

DALOA

DANANEDIMBOKRO

DIVO

DUEKOUE

FERKESSEDOUGOU

GAGNOA

GUIGLOISSIA

KATIOLA

KORHOGO

LAKOTA

M'BAHIAKRO

MAN

MANKONO

ODIENNE

OUME

SAKASSOU

SAN PEDRO

SASSANDRA

SEGUELA

SINFRA

SOUBRE

TABOU

TIEBISSOU

TOUBA

TOUMODI

VAVOUA ZUENOULA

TOULEPLEU

BONDOUKOU

ADZOPE

ABOISSO

TANDA

BONGOUANOU

ALEPE

ADIAKE

ABENGOUROU

BOCANDA

AGNIBILEKROU

TENGRELA

YAMOUSSOUKRO

GRAND-LAHOUZones under control of FAFN

Zones under control of the government

DPT3 coverage: 16%

Zone affected by war

National DTP3 coverage 50% in 2004

UNICEF Focal point (TA)

UNICEF

Health facilities offering services

579

302

395

447

497513

0

100

200

300

400

500

600

Nu

mb

er

of

he

alt

h f

ac

ilit

ies

before crisis Aug 04 Dec 04 Mar 05 Jun 05 Oct 05

Number of health facilities, offering health services in the zone affected by the crisis

Measles catch-up campaign

Aug 05

UNICEF

Capacity building through measles catch-up campaign

Micro-planning

Training Health Workers on vaccination, injection safety

Training of Community Health Workers

Cold chain• National and 2 regional freezer rooms• 224 Refrigerators and freezers for HC • Reparation & maintenance of cold chain

equipment

Building of 4 incinerators

UNICEF

Measles micro-plan

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>15km

5-15km

<5km

Map outMap outWhere, Where,

How many How many Children Children

livelive

UNICEF

Diarrhea

Malaria

MeaslesPneumonia

Neonatal

Others

Diarrhea Malaria Measles Pneumonia Neonatal Others

Why do Ivorian children die?

UNICEF

Coverage of 7 interventions

4%

10%

0%

0%

0%

16%

16%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

AnteNatalCare3

TT2+

ITN use

De-worming

Vitamin A

DPT3

Measles 1

missed opportunities

Rationale for integration of other interventions (2004 crisis affected districts) *)

Source : DC-PEV, RH Cote d’Ivoire (administrative data)

UNICEF

Coverage of 7 high impact interventions

6%

0%

28%

76%

82%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ITN use *)

Vitamin A §)

DPT3 *)

Measles 1 *)

missed opportunities

missed opportunities

missed opportunities

Rationale for integration of other interventions (2006)

Source: (1) MICS 2006 & (§) DC Nutrition Reporting data (routine program)

UNICEF

Possible reduction in child mortalitycoverage % CMR increase

reduction

• Measles 16 – 82% 2.8%

• Vitamin A supplementation 0 – 82% 3.3%

• ITN use 10 – 60% 9%

• Source: MBB

UNICEF

At 9 months

MeasleMeasless

Yellow Yellow FeverFever

Vitamin AVitamin A

ITNITN

UNICEF

Micro – planning EPI+ & Focused ANCWHERE & HOW MANY?

Mapping of population & un - reached children per localityWHEN?

Planning of outreach sessions, with community membersWHAT?

– Bundled vaccines– Vitamin A– De-worming tablets– ITNs– SP for IPTp– Iron tablets

HOW? Fuel and per diem

UNICEF

Guidelines for micro-planning

CANEVAS DE MICROPLANIFICATION DES ACTIVITES PREVENTIVES DE L’AIRE DE SANTE A . ANALYSE DE LA SITUATION I . INFORMATIONS GENERALES SUR L’AIRE DE SANTE

JJ MM AAAA Date _______/______/_______

1.1. Nom de l'Aire de Santé : 1.2. Type de l’ESPC* : Urbaine /____/ Rurale /_____/

1.3. Nom du district sanitaire : 1.4. Nom de la région sanitaire :

1.5. Nom du Responsable Centre de Santé :

1.6. Distance entre le village le plus éloigné et le Centre de Santé (Km) 1.7. Distance entre le village le plus proche et le Centre de Santé (km) * Etablissement Sanitaire de Premier Contact 1.8 Population de l’aire de santé

a) Population totale

c) Pop. d’enfants de 0-11 mois (2,95% de pop. totale)

d) Pop. d’enfants de 12-23 mois (2,56% de pop. totale)

e) Pop. d’enfants de 0-59 mois (17,39 % de pop. totale)

f) Pop. d’enfants de 6-11 mois (1.5 % pop. totale)

g) Pop. d’enfants de 12-59 mois (14.44% de pop. totale)

h) Pop. des femmes 15-49 ans (23,26 % pop. totale)

i) Population des femmes enceintes (5% de pop. totale)

j) Population de naissance attendu (4,7% de pop. totale)

k) Pop. d’enfants de 6 mois 14 ans (43,58 % pop. totale)

l) Source d’information des données démographiques

Situation analysis ofDemographics,

Human Resources,Performance &

Development of micro-plan

At Health Facility level

UNICEF

Objectives of the micro - plan

Results based planning with

coverage of intervention as outcome

At Health Facility level

UNICEF

Outreach plan MBengue (1)Centre de sante: CSU M'Bengué

1 M'Bengue 7687 227 19 384 32 0 150Souhouo 334 10 1 17 1Souhoua 147 4 0 7 1

Total strategie fixe 8167 241 20 408 34 5 0 150 8 0circuit 1 582 17 1 29 2 0.5 20 0.5 1,500

Fondo I 145 4 0 7 1 20Fondo II 0 0 0 0 0 14

1 Sindjougou 437 13 1 22 2 20circuit 2 269 8 1 13 1 0.5 30 0.75 1,500 1 Tietougou 269 8 1 13 1 30

Total S. Avancee 851 25 2 43 4 1 50 - 1.3 3,000 circuit 3 1,840 54 5 92 8 1 48 2 3,000

Gara I 0 0 0 0 0 40Gara II 0 0 0 0 0 48Loukpoho 0 0 0 0 0 48Sandrigue 1840 54 5 92 8 34

circuit 4 1368 40 3 68 6 1 38 1.9 3,000 Kassalgue 417 12 1 21 2 38Sanhara 388 11 1 19 2 34Soleyaha 563 17 1 28 2 32

Autre 176 5 0 9 1 0 34Korloho 0 0 0 0 0 28Wiriguevogo 0 0 0 0 0 28Woklo 0 0 0 0 0 26Yenifori 0 0 0 0 0 26N'Golokaha 176 5 0 9 1 34

Total S. Mobile 3,385 100 8 169 14 2 48 - 4.3 3,000 Total aire de santé 12,403 366 30 620 52 8 98 150 13 6,000

% réel PC affecté à SF 66%% réel PC affecté à SA 7%% réel PC affecté à SM 27%

Carburant mensuelPop cible 0-

11 mois mensuel

Pop cible Femmes enceintes

annuel

Pop cible Femmes enceintes mensuel

Distance CS-Village A/R

ou circuit(km)

Distance CS-DS A/R

Population totale 2006N°

Quartiers /villages

Pop cible 0-11 mois annuel

CollationNo seances ou sortie par

mois (arrondi)

WHERE&

HOW MANY

UNICEF

Outreach plan MBengue (2)

S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S4S1S2S3S41 M'Bengue Dispensaire

SouhouoSouhoua

Total strategie fixecircuit 1

Fondo I Chef de villageFondo II Chef de village

1 Sindjougou Chef de villagecircuit 21 Tietougou Chef de village

Total S. Avanceecircuit 3

Gara I Chef de villageGara II Chef de villageLoukpoho Chef de villageSandrigue

circuit 4Kassalgue Chef de villageSanhara Chef de villageSoleyaha Chef de village

AutreKorlohoWiriguevogoWokloYeniforiN'Golokaha

Total S. Mobile

2x

N°Quartiers /villages

Dates de passage des équipes

decjan fev juillet aoutLocalisation site de vaccination

novoctsepmars avril mai juin

WHEN

UNICEF

Input needsStratégie Opérationelle: SYNTHESE DE L'AIRE

Doses Nb Bte/Flacon Nb Bte/Flacon arrondi

BCG 0-11 mois 293 24 flacon de 20 dose 61 3.0 8DTC 0-11 mois 293 24 flacon de 10 doses 122 12.2 25POLIO 0-11 mois 293 24 flacon de 10 doses 122 12.2 23VAR 0-11 mois 293 24 flacon de 10 doses 41 4.1 10FJ 0-11 mois 293 24 flacon de 10 doses 41 4.1 10VAT FE 434 36 flacon de 20 dose 120 12.0 13Seringues BCG 0-11 mois (BCG) 293 24 boite de 100 34 0.3 3Seringues Autobloquante0-11 mois / FE (DTC_HepB, VAR, FJ, VAT) boite de 100 270 2.7 9Seringues a dilution 0-11 mois / FE (VAR, FJ) unite 11 11.2 37Boites de securite 0-11 mois / FE (BCG, DTC_HepB, VAR, FJ, VAT) unite 3 2.7 9

VIT A 100.000 UI 6-11 mois 293 24 34 0.1 3Vit A 200.000 UI 12-59 mois 1,433 119 1 fois tous les 6 mois 328 0.7VIT A 200.000 UI Femme en Post-partum Immediate 408 34 2 doses en 24 heures 85 0.2

Fer/Folate FE 434 36 boite de 1000 comp 4,070 4.1 9SulfoPyri FE 434 36 boite de 100 comp 271 2.7 4Mebendazole 500 mg 0-11 mois et FE 727 61 boite de 100 comp 76 0.8 4MII 0-11 mois et FE 690 58 unite 72 71.9 105

Nb litre Cout FCFA14 8,795

Nb de sortie Cout FCFA3.0 6,000

TOTAL 14,795

3

Cible par mois

ObservationAntigènes Besoins

Carburant

Collation

Groupe cibleCible

par an

WHAT &

HOW

UNICEF

Results – Districts affected by crisis & Abobo (Abidjan) & San Pedro

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

# o

f c

hild

ren

va

cc

ina

ted

BCG DTPHepB Measles Yellow Fever

2004 2005 2006

6,431 more children vaccinated6,431 more children vaccinated 26,554 more children vaccinated26,554 more children vaccinated

Objective 60% for 2006Objective 60% for 2006

UNICEF

In summaryIn summary

• Measles campaign micro – planning can Measles campaign micro – planning can be applied to routine activitiesbe applied to routine activities– Tailor outreach activities by health facilityTailor outreach activities by health facility

• Use data for choosing type interventions Use data for choosing type interventions and set targetsand set targets

• Measles vaccinations (campaign and Measles vaccinations (campaign and routine) are optimal moments to deliver routine) are optimal moments to deliver other life saving interventionsother life saving interventions– Reduce child mortality even moreReduce child mortality even more

UNICEF

Measles InitiativeMeasles Initiative Working Together to Save Lives Working Together to Save Lives

JapaneseGovernment

Ministère de la Santé – Cote d’Ivoire