End Preventable Deaths of Women and Kids in Togo

Integrate Health Launches Patient Care in Guinea

On December 1, 2023, World AIDS Day, Integrate Health launched patient care in the Kouroussa district in Guinea! This day, globally dedicated to raising awareness about AIDS, is a tribute to our history and our roots. Nearly two decades ago, Integrate Health was founded in partnership with individuals living with HIV in northern Togo. It was founded on the idea that no one should die from a disease we knew how to treat. Now, the extension of the Integrated Primary Care Program to Guinea, serving 111,750 people, including approximately 16,000 children under five and 28,000 women, means that we are one step closer to ensuring the right to health for all. This significant stride underscores our commitment to build a more equitable future where everyone, everywhere has access to essential health services.

Since the launch of patient care, the momentum and impact of Integrate Health’s efforts are visible in Kouroussa. Five supported health centers have witnessed a significant increase in patient visits; essential care was provided to 1,248 children, 403 pregnant women, and 40 postpartum women in the first month alone. Integrate Health trained and deployed 130 Community Health Workers (known as Community Relays in Guinea). In addition, 71 “zero-dose” children—those who have not received any childhood vaccinations—were identified, and efforts to vaccinate them are in full swing, with 43 already receiving lifesaving vaccines in the program’s first month. Since program launch, Integrate Health has also successfully supported Kouroussa district vaccination teams in performing 62 community outreach vaccination days, during which vaccination agents and prenatal care midwives travelled from Integrate Health-supported health centers to rural communities to vaccinate children and pregnant women. To read more about program launch in Guinea, please visit this blog featured on the Integrate Health website.

And this is just the beginning. Integrate Health’s partnership with Gavi, the Vaccine Alliance, and the Guinean Ministry of Health is laser-focused on demonstrating impact and replicating evidence-based interventions to make the primary healthcare system work for all Guineans, and beyond. Priorities for the next six months include implementing and improving the monitoring and evaluation processes, digitalizing tools to improve data quality and patient care, and engagement with traditional healers to build a strong a referral network across communities in Kouroussa.

Togo Highlights

Successes

Digitally enabled Community Health Workers (CHWs): As of October 2023, all 170 Integrate Health-supported CHWs in Togo are fully digitally enabled! Integrate Health trained 40 CHWs from the Binah district on the digital health app Tonoudayo. The week-long training supported CHWs to transfer from paper forms to the digital tool for patient registration and tracking, consultation decision support, and reporting. The newly trained CHWs are working to register each household in their catchment areas onto the app. Binah is the fifth and final Integrate Health-supported district to transition to the electronic tool. In addition, Integrate Health’s Innovation and E-Health teams are working together to integrate the management of medication stocks into the app.

Prenatal Laboratory Program and Evaluation: In December, Integrate Health’s research team evaluated a free prenatal lab testing program, an innovation added to the core Integrated Primary Care Program in Togo. In 2021, while access to and quality of maternal healthcare increased in communities supported by Integrate Health, less than 20% of pregnant women attended prenatal care in their first trimester, and about 25% of child deliveries still occurred at home. After hearing from patients and providers that the financial barrier to lab testing was deterring women from seeking timely prenatal care, Integrate Health added essential lab tests to the package of free maternal health services. After two years of implementation, the research team evaluated maternal health data: pre- and post-program implementation, from Integrate Health and national data sources, comparing results across Integrate Health-supported and non-supported sites. Results indicated that over the two-year period, 15,850 pregnant women benefitted from the program, representing 95% of all pregnant women in the catchment area. In communities where prenatal labs were free of charge, the data shows a 79% increase in prenatal consultations in the first trimester of pregnancy, a 120% increase in the number of women receiving at least four prenatal visits before delivering, and a 9% reduction in home births. These promising results will be further explored with qualitative interviews, and results will be shared widely within Togo to advocate for an expanded package of universal maternal healthcare. Read the full story here.

Evaluation of the Rural Ambulance Program: In November, Integrate Health's research team concluded an evaluation of the effectiveness of the Rural Ambulance Program in Togo, another innovation that was added to the core Integrated Primary Care Program in 2018. Retrofitted tri-motorcycle ambulances are used to transport patients during emergency situations, therefore reducing barriers to accessing critical care. The evaluation focused on the proportion of pregnant women with complicated obstetric cases who were transported through the ambulance program. Between 2020 and 2023 in Bassar, Dankpen, Kéran, and Binah districts, 2,926 pregnant and postpartum women were transported by the ambulance program. Of these, 1,030 (35%) had obstetric complications and represented 66.5% of estimated expected obstetric complications in the catchment area population. Results indicated that as the program expanded to more districts, coverage increased for women with obstetric complications. Overall, this evaluation showed that a majority of women expected to experience complications are being effectively transported to access higher levels of care. These encouraging results will be shared with MOH partners who are committed to improving transport systems, and opportunities to scale up the ambulance program will be explored.

Challenges

National CHW reform in Togo: Integrate Health’s continued work with the MOH in Togo to pilot the national CHW policy reform is advancing slower than we hoped. Integrate Health has embedded a technical assistant within the MOH’s division of community health to coordinate the pilot program. Over the past year, the coordinator has led the process of creating a CHW master list, identified priority districts for pilot implementation based on health needs, developed a pilot strategy and budget, and successfully enticed new interest from partners including the Global Fund and Gavi, the Vaccine Alliance. Currently the technical assistant and government leaders are developing a detailed operating plan and funding agreement for partners supporting the pilot, including Integrate Health. Integrate Health plans to accompany the government to support 150 CHWs serving 113,000 people in one district.

Guinea Highlights

Successes

Data Quality Improvement: As part of efforts to strengthen vaccination data quality, Integrate Health conducted a baseline evaluation in the Kouroussa district to gather baseline figures of key performance indicators (KPIs). Integrate Health recruited a consultant to perform a household survey, which was completed in September. The results were analyzed, and an internal report was completed at the end of October. In November and December, the Monitoring, Evaluation, and Quality Improvement team worked to triangulate baseline figures collected from the household survey with DHIS2 data, and ultimately created a list of baseline figures and associated targets with as much accuracy as possible.

In the DHIS2, childhood vaccination coverage rates (Penta-3) were found to be 90% in Kouroussa. However, the household survey data from the baseline evaluation found a 45% coverage rate. Therefore, Integrate Health has set 45% as the baseline value for this key indicator, with the objective of reaching 67% in year one, 80% in year two, and 90% in year three. Clinical Mentors will continue to work with health center staff on proper vaccination data collection and reporting to improve data quality.

Health Center Assessments: An essential pillar of the Integrated Primary Care Program is ensuring that health centers are fully equipped with medicines and supplies and have the infrastructure needed to provide a welcoming environment to patients and a safe work environment for staff. At the start of the program in Kouroussa, Integrate Health performed a needs assessment in the five supported health centers to note any missing human resources, equipment, or infrastructure. During this assessment, Integrate Health identified a health center in Douako, which will serve as a referral center for nearby communities separated by the Niger river. The river makes it difficult for those communities to access the main referral center, the district hospital in Kouroussa. Integrate Health prioritized equipping Douako with missing equipment (including blood pressure readers, aspirators, and other childbirth essentials, etc.). Integrate Health also recruited a pediatrician and a gynecologist, and the recruitment of an anesthesiologist is still underway. These staff will work at the Douako health center, to ensure that the health center is ready to receive cases referred from other Integrate Health-supported sites.

Challenges

Nutrition treatment stockout: In Guinea, after the launch of patient care in December, it quickly came to Integrate Health’s attention that many of the children being referred to tertiary (hospital level) care by CHWs and health centers were suffering from malnutrition. In December, the Kouroussa district hospital was out of stock of ready-to-use therapeutic foods needed to treat severely malnourished children, as well as treatment regimens (notably F100 and F75 milks) for severe malnutrition cases with complications. The Integrate Health team raised this issue with MOH partners at the district, regional, and national levels to advocate for a resupply. As of January 2024, Integrate Health is in close contact with UNICEF’s nutrition lead in Guinea, who is working on distributing malnutrition treatment regimens to Kouroussa’s district health team. To prevent future stockouts, the Integrate Health team is gathering data on the number of malnutrition cases in the district to advocate for improved stock availability. Simultaneously, Integrate Health-supported CHWs are providing health education to families on how to prepare nutritious food at home to prevent malnutrition.

Organizational Highlights

Successes

International Conference on Public Health in Africa (CPHIA 2023): In November, Integrate Health’s Research Manager, Dr. Désiré Dabla, attended the CPHIA 2023 in Lusaka, Zambia, and presented findings from a study entitled "Characterizing motivation among female Community Health Workers in northern Togo, 2021-2022.“ The results of the study highlighted several factors influencing the motivation of CHWs, such as changes in social status, satisfaction with training, financial benefits, clear definition of objectives, perception of positive feedback, and management support. Questions at the end of the presentation asked about the decision to focus the study on female CHWs and how these results might differ from a male population. In future analyses, some recommendations will be considered such an analysis of motivational factors according to age group.

A call for strategic investment in primary healthcare across Africa: On Universal Health Coverage (UHC) Day on December 12^th, Integrate Health’s CEO, Jennifer Schechter, published an article in which she discussed the gap in funding for community health services and highlighted pathways to bridge the gap in financing. The article calls on the international community as well as national and local governments to invest in integrated community primary healthcare initiatives as a route to achieving UHC and highlights the importance of CHWs in improving healthcare access and quality. To learn more, you can read the full article on Integrate Health’s website here.

Challenges

Departure of Deputy Country Director in Togo: After three impactful years, our Togo Deputy Country Director, Anita Kouvahey-Eklu, is leaving Integrate Health. During her tenure, Anita built a strong partnership team in Lomé and stewarded a government accompaniment strategy that will continue to serve the organization after her departure. In the wake of her departure, a key member of her team, Dr. Charlotte Dzamado, has been promoted to Partnership Director. Anita will remain a close collaborator. We wish her all the best in the next chapter of her career!

Financial Highlights

• This quarter, Integrate Health received generous renewal funding from six partners. We remain grateful for your continued support and are excited to be able to continue providing lifesaving primary care to communities in need in Togo and Guinea.
• The Human Resource teams in both Guinea and Togo have decided to replace the use of Payspace for payroll functions. This is because of challenges using the platform due to language barriers. Both teams have partnered to find a solution that works across both countries, and we expect a new provider will be selected by the next quarter.

Links:

• IH website