Integrating NCD interventions:

PSI’s experiences to date

Rebecca Firestone, ScD, MPH

May 1, 2012

PSI is a leading global health organization - social

marketing is the core of our work

Social marketing is about making it easy for people to

change their behavior

PSI reaches our target audience where they are

– Most people in the developing world get healthcare through

the private sector

– PSI leverages the private sector - providing training, new

tools, and franchised clinics

We focus on measurement, learning and innovation

Operations in 67 countries

What is PSI

Zimbabwe LesothoMalawi

BotswanaNamibiaUganda

ZambiaSwazilandCongo-Kinshasa

MozambiqueKenya

Tanzania

South Africa CameroonMadagascarRwanda

Benin Cote d'Ivoire MaliBurundiNigeriaEthiopiaAngola

Togo

MyanmarPakistan

LiberiaCambodiaC.A.R.Guinea South Sudan

Cote d'Ivoire (AIMAS)Haiti

Nepal IndiaTajikistan

Papua New GuineaLaosThailand Burkina Faso

Paraguay

Mexico

Costa Rica

Romania

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PSI Relevance: 2011 Global DALYs Averted Compared to Burden of Disease (WHO 2004)

Innovation in NCDs + Injuries

Innovation in communicable burden

Expansion

Relevance

% DALYs Averted by PSI

% of National BODranked by % relevance

Our experience to date

Screening, diagnosis and management of gestational diabetes

in Nicaragua

Operating in 3 public sector clinics and 1 maternity hospital in

urban and per-urban Managua

Train public health care providers on risk factors for GDM; how

to screen for and detect GDM; proper management and care of

GDM

Establish formal referral and feedback systems between clinics

and hospitals for improved detection and management of GDM

Screen 750 pregnant women/month between 24-30 weeks of

gestational age for gestational diabetes

Enroll women with gestational diabetes in a management

program

– Nutritional therapy sessions, individual and group counseling for women

and their families, GDM management guide, follow-up reminders via

mobile SMS

Program strategies

Screen for ≥1 risk factor through clinical interview

– Overweight

– Family history of diabetes

– Unfavorable obstetric outcomes including: GDM or pre-diabetes in previous

pregnancies, 2 consecutive miscarriages, fetal death without an apparent

cause, macrosomia

Diagnose GDM: fasting oral glucose tolerance test in the 24th week with

75g of glucose (with 8 hours of fasting prior to the test)

– Fasting glucose ≥92 mg/dl

– 1 h ≥180 mg/dl

– 2 h ≥153 mg/dl

– Nutritional counseling during wait time

Screening protocols in a low-resource setting

Leverage existing RH connections with

government, provider networks, and medical

associations

Maximize current capabilities in

– Training health care providers using behavior change

strategies

– Quality assurance

– Behavior change communications for women via mHealth

Key challenges

– Low levels of knowledge about GDM among pregnant

women

– Inconsistent information provided to women with GDM

across internist, gynecologist, nutritionist

Lessons learned so far

Cervical cancer screening and treatment in Myanmar

Build off of existing family planning platform

– Link to provision of IUDs and other contraceptives

Train 47 providers in VIA at 47 franchises

Train 10 providers in cryotherapy

– Hub and spoke approach to direct women from screening to

treatment sites

Aim to

– Screen 20,000 women

– Treat 2,000 women with cryo

– Prevent 300 cases of cervical cancer

PSI Health Impact Model estimates that 10,000

women screened and treated = 1,006 DALYs

Piloting VIA + cryotherapy in a social franchise

Social franchise network provides a flexible platform

to integrate a range of services

Need for advocacy with the medical professional

community

– Task-shifting from OB/Gyn to GPs

– Proving sensitivity/specificity of VIA, safety/efficacy of cryo to

local stakeholders

Challenges in procuring equipment

– High costs of cryo guns

– Delays in receiving import licenses

Lessons learned so far

Where we want to be going

Tuberculosis and Tobacco

More than 20% of global TB incidence may be attributable to

smoking tobacco

PSI TB programs in 12 countries

– Screening and treatment through social franchises

• 91% treatment completion in Pakistan; 85% completion in

Myanmar

– Screening and referral linked to HIV TC centers

• 91% of HIV testing clients screened for TB in Zimbabwe

Aim for smoke-free facilities

Identify and assess tobacco use status among TB clients

– WHO “5 A’s” algorithm for those willing to quit

– Who “5 R’s” motivational intervention to promote quitting

Integrate tobacco messaging into community outreach to TB

clients and families

Tuberculosis and tobacco

An expanded approach to cervical cancer

Into reproductive health programs

– Scaling up screen+treat via social franchises

– Establish mobile services

– Introduce HPV vaccination (Nicaragua)

Into HIV testing and counseling (HTC)

– PSI operates HIV testing and counseling in 30 countries

– 1.4 million people tested and counseled in 2011

– Variety of modalities: social franchises, mobile clinics, stand-

alone clinics

– HTC emphasizes integration – with FP, TB. Why not

cervical cancer?

Cervical cancer service integration

An expanded approach to cervical cancer programs

Behavior change communication

– Cervical cancer screening and treatment

– Vaccine uptake

Incentivized care

– For providers and/or participants

Advocacy

– Ministries of Health and Education

– Medical professional organizations

Hypertension and diabetes: the next frontier for franchising

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PSI

Range of franchised services provided, 2011

Challenges for SF and NCDs

Thank You!

Questions?

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