FeaturedWHO is the COHESION Project?

COHESION is the acronym of COmmunity HEalth System InnovatiON Project. It brings together institutions from Mozambique (Universidade Eduardo Mondlane), Nepal (B.P. Koirala Institute of Health Sciences), Peru (Cronicas Centre of Excellence in Chronic Disease at the Universidad Peruana Cayetano Heredia) and Switzerland (University of Geneva, Geneva University Hospitals, Graduate Institute and the Università della Svizzera italiana) with a focus on improving the management of Noncommunicable (NCD) and Neglected Tropical diseases (NTD) at Primary Health Care (PHC) for vulnerable populations.

Rather than focus on the “what” of the project: NCDs, NTDs and PHC; or the “how”: mixed methods, co-creation, innovative, adapted interventions at the community level and active communication with a variety of stakeholders, the first blog post of the COHESION Project will be on the “who”.

So who is the COHESION Project? The core team is comprised of leading academics in the fields of public health, epidemiology, clinical medicine, economics, sociology, gender, social marketing, communication, and anthropology. With many years of experience in different settings and across disease areas, the COHESION Team brings together a unique group of people. The sum of these individuals is an exceptional team with a unique set of skills and experience.

How did this team come together? This team is brought together by long-standing working relationships, joint projects, membership of similar networks, but most importantly a shared vision of:

  1. Mutual learning
  2. A focus on the most vulnerable
  3. Health systems strengthening
  4. Robust design and evaluation of complex interventions

The proposal and its approach were developed by the whole team building on the needs of the most vulnerable populations in the three countries as well as on the skills and expertise of the country groups and their members. Together we agreed on the proposal and its approach and in doing so became a cohesive team and highly motivated to make the COHESION Project a success.

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Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

Summary: Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

On May 3, the COHESION project in Peru held a meeting with stakeholders, where stakeholders related to the health sector and the diseases related to the project (diabetes, hypertension and neurocysticercosis) were invited. The purpose of the meeting was to present the project, create links with different institutions and receive inputs or recommendations for the project.

The meeting was attended by members of the COHESION project in Peru, part of the COHESION team from Switzerland, public officials from both the Ministry of Health and the Superintendence of Health, as well as some civil society organizations such as the Diabetes Association of Peru and the Peruvian Federation of rare diseases.

The meeting began with the words of welcome from Jaime Miranda, Director of “CRONICAS center of excellence in chronic diseases”. During his welcoming he remarked the intention of the meeting to carry out a co-creation process between the COHESION project and the assistants, to think together ways of improving the health system, especially in the attention given in the primary health care.

Following, David Beran principal investigator of the COHESION project made a presentation of the project COHESION (in Spanish). He explained the linkage between the project with the Millennium Development Goals and the Sustainable development objectives. He also pointed out important qualities of the project like being a multidisciplinary and multi-country team. Finally he explained the different stages that the project has carried out and the stages to come in the next years.

Subsequently, the words were given by María Kathia Cárdenas, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. During her presentation she explained the COHESION project in the Peruvian scenario. She specified the project is being carried out in the region of Piura, in the health posts of Sicacate and Pingola, located in the districts of Montero and Ayabaca respectively. During this presentation it was also specified two of the studies that the project is carrying on, the evaluation of policies and the health system assessment. She explained details of each study and the different levels of analysis. Furthermore, she also explained the methodology that is being implemented based on the manual “How to investigate access to care for chronic noncommunicable diseases in low and middle income countries” (2012) from the WHO, and she also explained the activities that were already performed at the community level such as interviews with patients, health workers, head of facilities, among others.

Next, María de los Ángeles Lazo, researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases, detailed the steps that will follow the project in the next months to involve the stakeholders at the macro or national level. She explained to the participants the important need of their support and expressed the intention of the project to involve them actively in the process, as well as with other key stakeholders. It was also specified that in the short term the COHESION project will be contacting them to have personal interviews, to know their opinions on the health systems facilitators and barriers.

Finally the discussion was opened to the attendees so they could express their opinions, comment or question of the project. This final part was moderated by María Amalia Pesantes, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. Some of the most important arguments and recommendations are detailed below:

  • To include the perspective of caregivers. It is important the health system recognized their task, not only in a financial support, but also to be trained in the care of the patients and to consider the importance of psychological support for the caregivers, who were also called “acompañantes” (companions).
  • Developing engagement with key stakeholders such as public officials and political representatives is a long-term endeavor.
  • It is necessary to establish relations with the regional health directorate in Piura. This entity is the responsible of providing the health service, while the Ministry of Health is in charge of regulating and monitoring. It was also suggested to interview the head of the department of Planning and Budget and Human Resources, and to include the Regional Government, who has also responsibilities related to health, poverty, access to water and sanitation.
  • It was also highlighted the important role played by community agents in the health system.
  • It was acknowledged the low ability of the Ministry of Health to communicate strong messages. Furthermore, civil society lack of relevant information about diseases, especially the most neglected population.
  • Past experiences on training diabetes educators were shared and it was noticed that one of the main difficulties in the training of health workers was the high rotation to other health establishments, and this should be taken in to account for the project.

Participants:

COHESION Team (Switzerland):

  • David Beran
  • Sarah Lachat
  • Suzanne Suggs
  • Nathaly Aya Pastrana

COHESION Team (Peru):

  • Jaime Miranda
  • Maria Kathia Cardenas
  • Maria Amalia Pesantes
  • Maria de los Angeles Lazo
  • Charlotte Darwis
  • Rosa Salirosa
  • Silvana Perez Leon

Participants:

  • Jorge Calderón (President of the Diabetes Association in Peru)
  • Luciana Bellido Boza (Representative of Intendance of Research and Development – SUSALUD)
  • Jorge Ferrandiz (Executive Director of the Department of Prevention and Control of Noncommunicable, Rare and Orphaned Diseases)
  • Maria Lourdes Rodriguez (President of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)
  • Lilliam Lindley (Representative of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)

 

COHESION – a challenge to Frenk and Gómez-Dantés

In The Lancet, in February 2017 (http://dx.doi.org/10.1016/ S0140-6736(16)30181-7), two leading thinkers in global health, Julio Frenk and Octavio Gómez-Dantés, challenged the status quo of many of today’s public health and healthcare delivery processes through a detailed assessment of a variety of dichotomies that exist in global health. Frenk and Gómez-Dantés’ main message was the need for integration in global health across a wide range of challenges. This interesting piece led to a thought provoking discussion within the COHESION Team where we asked ourselves: are we operating within or beyond those scenarios of dichotomies?

The first dichotomy they describe is the prevention versus treatment debate. How does COHESION address this first dichotomy? For non-communicable diseases (NCD), even if all prevention measures are successful some people will still develop some of the conditions included in this overarching group. For Neglected Tropical Diseases (NTD) the “endgame” for many of these diseases is envisionable given the existence of medicines which provide a “magic bullet” to cure people and/or break the cycle of transmission. However, for both NCDs and NTDs people have already been exposed to some of the risk factors, have biological changes (e.g. high blood pressure; infected with Cysticercosis) and therefore require care. Yet, both NCDs and NTDs share fundamental root causes that determine its existence: poverty and exclusion. We cannot address treatment solely without the broader need for prevention.

The next “clash” described is the vertical versus horizontal debate. For NCDs and NTDs this debate is mute as the main driver of vertical programmes was funding. As was seen for HIV/AIDS funds were allocated to create complete vertical systems for distribution of medicines, training of health professionals, delivery of care, etc. For both groups of diseases that COHESION focuses on this funding is lacking thus vertical solutions are not implemented. That said NTDs are more at risk of becoming “verticalised” given the higher level of funding available in comparison to the burden, the “easier” solutions of mass drug administration (for some NTDs) and the defined populations that are impacted by some diseases. COHESION through its research and development of interventions will try to ensure a horizontal approach in order to benefit not only those with NCDs and NTDs, but any one requiring health care at primary level. We are allowing ourselves to redefine the interaction of an individual with the existing healthcare system where chronicity and continuity of care are fundamental.

Number three on Frenk and Octavio Gómez-Dantés’ list is primary versus specialized care. As mentioned above the main focus of COHESION is on primary health care. Given that our emphasis is on NCDs and NTDs which are both chronic in nature this will enable a strengthening of primary health care to guarantee continuity of care. Traditionally primary health care has been successful in maternal and child health, delivery of HIV/AIDS care (with significant funding) and acute care. However, with the burden of chronic disease a shift in the role of primary health care is needed. Through its formative research and interventions COHESION will focus its efforts on developing this level of the health system. We are not denying care, but aim integrate chronic care at primary health care as well as facilitate referral to specialized care when needed.

By design COHESION lays the fourth dichotomy to rest, the noncommunicable versus communicable disease prioritisaiton. By including NCDs and NTDs together within the core of its project COHESION wanted to focus on models of delivery of care versus mode of transmission. Leprosy and Type 2 diabetes from a delivery of care perspective share many similarities despite being communicable and noncommunicable. Need for proper diagnosis and initiation of treatment; patient education and empowerment; address issues of stigma; and prevention of complications.

Finally, the latest dichotomy posed the challenge between knowledge generation versus action. Again, COHESION is in a unique position thanks to the funding mechanism developed by the Swiss National Science Foundation and Swiss Agency for Development and Cooperation. The funding COHESION has received will not only enable the generation of new knowledge on NCDs and NTDs, at policy, health system and community level, but also to use this to co-create innovative interventions working closely with local partners through.

The title of Frenk and Octavio Gómez-Dantés’ comment includes the word “integrative”. COHESION in the design of its team and project has had this word as a guiding principle. Integration of different expertise from a variety of countries, institutions and individuals; different diseases and disease groups; different methodological approaches; local partners and stakeholders in the research and intervention development. As COHESION we would add another dichotomy to the list proposed by Frenk and Octavio Gómez-Dantés that is how solutions in global health are developed. Most solutions to date have had their roots in meetings at the World Health Organization, the minds of the best and brightest academics and in the offices of Ministries of Health. Our approach proposes a bottom up approach where interventions are informed by this, but designed by beneficiaries. To date although different normative documents exist on how to tackle the burden of NCDs and NTDs success is still far away. We hope through our innovative approach to find ways of addressing NCDs and NTDs as well as contributing to breaking down the dichotomies that Frenk and Octavio Gómez-Dantés highlight.

 

Written by David Beran and Jaime Miranda for COHESION

 

 

 

 

 

 

 

COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!

COHESION PI reflects on “Meu regresso a Moçambique”

Meu regresso a Moçambique – My return to Mozambique

Mozambique is a special place for me. It was the first country I visited in sub-Saharan Africa, my first project in looking at diabetes management in a low-income country and also a country where I was able to work for close to 7 years with the Ministry of Health and Diabetes Association. Besides the professional aspect, it was also a place where I made long lasting friendships with unique people who not only shared their passion for the work we were doing together, but also imparted me with the love of their beautiful country.

So the question I got from everyone after my recent trip to Mozambique for COHESION, how was it going back? AMAZING was my answer.

Going back to Mozambique was like seeing an old friend after a long time. The link, fondness and memories were there. Both Mozambique and I had moved on since my last visit. Economic development in Mozambique, but with current economic turmoil, more projects including the launch of COHESION and my move back to Geneva on my end.

My reunion with Mozambique was also positive in that the Mozambique COHESION Team had progressed with the research, been able to involve high-level individuals in the Advisory Boards as well as gain the support for our project in the two areas where our work will take place. I had a chance to visit Xipamanine and Moamba and speak to health professionals and local members of the community. In parallel Dr. Claire Somerville (Graduate Institute and COHESION Project Lead on the Policy Analysis component) and Sarah Lachat (University of Geneva, COHESION Project Manager) had the opportunity with our colleagues to work on and carry out some interviews regarding the Policy Analysis. We were also able to meet with the Swiss Cooperation Office in Maputo. The result of all of these discussions is that COHESION has a huge role to play in Mozambique to help improve the management of Noncommunicable (NCD) and Neglected Tropical Diseases (NTD).

Being back in Mozambique not only enabled me to see progress and continuing challenges based on my previous work, but mainly the importance of the current work of the COHESION Project. There are many challenges in Mozambique with a life expectancy of 53; high prevalence of HIV/AIDS and malaria; high maternal mortality, etc. NCDs and NTDs have been neglected by policy makers and donors. This results in a lack of capacity at the level of the health system to respond, leading to challenges for individuals and communities. The interventions that our project will develop will hopefully address these and help improve the conditions for people with NCDs and NTDs.

Até a proxima (until next time) Moçambique,

Dr. David H. Beran, Principal Investigator of COHESION

Swiss team goes to Mozambique

The COHESION team meets in Mozambique. Three members of the Swiss team (Dr. David Beran, Dr. Claire Somerville and Mrs. Sarah Lachat) join the Mozambique team this week at Eduardo Mondlane University.

Policy Analysis and gender are at the top of the agenda, but the team will not miss the opportunity to advance the community and health system assessments and reporting.

The team is grateful to be able to profit from face to face time in the country.

Preliminary results from Household Survey in Nepal

Preliminary findings of the household survey in Nepal show that a total of 6245 people lived in 1209 households with an average family size of 5.17 ±2.02. Females were lesser in proportion (48.8%) than males and most of the people were living in nuclear families (64%). About one fourth of them were illiterate. The main source of drinking water was tube well among majority (97%) of the households and most of the households (68.2%) used firewood as a source of fuel for cooking. A quarter of households still practiced open field defecation. More than three fourth of them (78.1%) living below the poverty line.

About 66% of the households consulted a health care institution for health problems in the past one year. Among those who had visited PHC (41.4%) for consultation, 93.8% reported of having received information about their health problems; however 20.6% of them did not get sufficient time to ask for clarification. Although 47% of them were referred to other health institutions, almost half of them rated the service of PHC to be good. Most of them (70.5%) could reach the PHC by walking and about 29% of them were not accompanied by anybody during the visit to the PHC.

Among the health problems reported, there were two cases of leprosy, more than 8% were diabetes and about 9% were hypertension.

 

Apart from health workers such as doctors, nurses, health assistants and auxiliary health workers, and female community health volunteer, people also seek advice regarding health problems from their friends (10.6%), relatives (23%), neighbor (7.1%) and traditional healers (12%). None of the people had any form of health insurance.

 

 

Household Survey in Nepal

For the first time, in the rural area, Baniyani VDC, Jhapa district, South-western Nepal, a major household survey on several health issues was conducted by the Nepalese COHESION team during the last week of November 2016. The aim of the survey was to collect baseline information needed to assess the level of NCDs and NTD prevalence and related health care in one of the two selected site for COHESION intervention in Nepal.

The Household survey was conducted in the framework of the Interdisciplinary “Community Diagnosis Program” organized by School of Public Health and Community Medicine which comprises of two weeks of residential posting in rural setting for 1st Year MBBS, BDS and B.Sc. Nursing students. More than 200 students took part to the survey, supervised by 30 postgraduates and teachers, to collect data of more than 1200 households.

The questionnaires used are an innovative mixture of closed and open-ended questions concerning the socio-demographic profile of the community, reported health problems, health seeking behaviour and access to health facility and services at PHC level from a consumer perspective.

An orientation program was first organized at the B. P. Koirala Institute of Health Sciences (BPKIHS) to deliver lectures for the students on the different methods to be used. A meeting with local authorities including VDC heads, health worker, leaders, school teachers, Female Community Health Volunteers and others was also organized the week before field work, to inform the community of Baniyani VDC about the program and its aim.

The total of 201 medical graduate and nursing students under the supervision of 26 supervisors, including MD/MPH/MSc. nursing students were grouped in nine groups in accordance with the total number of wards of Baniyani VDC and performed house to house visits during 7 full days and collected more than 1200 households using semi-structured questionnaires regarding the above mentioned issues.

All households of the VDC were visited. The local communities were very cooperative in general. However, some resisted for the interview which could be due to mistrust towards health institutions or business. Others could not be assessed because of locked houses, probably due to the harvesting season or migration for work. Some members of household questioned about benefits of the survey: the fact that we were holding a health camp in parallel (day program of on the spot consultations offered by the MDs/faculties from B. P. Koirala Institute) helped a lot in this regard. At the end of the data collection exercise preliminary findings were shared with the community representatives, which also fostered mobilization of the villagers.

A challenge of the survey was to visit the place of study from the place of residence with such a huge group of students. We had to travel for more than an hour by bus. We all were very busy during the data collection with regard to visiting different households by walking. In every evening, attendance of students and briefing of status of data collection was organized.

In general, this survey was a success. Not only data were collected, but because all students had the opportunity to gain a lot of valuable experience.

The selected sites of Ayabaca and Montero in Piura – Peru

The COHESION project assesses the barriers that underserved communities face when accessing Primary Health Care (PHC) to treat chronic conditions in Peru, Mozambique, and Nepal. In Peru, the selected districts are Ayabaca and Montero in the Ayabaca province of Piura, North-Peru.

The northern region of Piura is well known for its tropical climate, white-sand beaches and surf. Far from the beaches on the coast, we find the province of Ayabaca in the highlands of Piura. Ayabaca is about six hours away from Piura city and it can only be accessed by road. Rural Ayabaca has often been neglected and forgotten by policy makers and private investors. Although blessed with rich flora and fauna, the Ayabaca province faces poverty and exclusion.

The Peruvian COHESION project team chose as its intervention sites two districts of the Ayabaca province: Montero and Ayabaca, where 6,683 and 38,339 people live respectively1. According to the National Institute of Statistic and Informatics, the poverty rate in Ayabaca is 69.4% and 55.9% in Montero1. One of the main problems in these districts is the lack of access to sanitation and clean water. Ayabaca province has one of the highest drinking water shortages and lack of basic sanitation, with wide differences between its urban (54%) and rural (99%) areas2. Lack of sanitation is one of the major risk factors3 for some Neglected Tropical Diseases like neurocysticercosis.

Access to health in places like Ayabaca is crucial and yet, scarce. Health facilities in both Ayabaca and Montero only provide very basic health services, focusing on maternal and child health. Out of the 31 health facilities in Ayabaca, 29 are basic primary health care posts. The other two are health centres. Montero, on the other hand, has only three basic primary health care posts and one health centre. The health centres have few health professionals and rudimentary hospitalization facilities. If there is an emergency in either of these districts that requires an urgent referral of the patient, the closest regional hospital is located in Sullana-Piura and it takes about four hours to get there by private vehicle. However, the ambulance in these health centres is not always operating. Addressing diseases like neurocysticercosis, hypertension, and diabetes in resource-limited districts like Ayabaca and Montero needs effective interventions that work at a community-based level and that are focused on the poorest of the poor.

Health Center – Ayabaca

 

Pingola Main Square

 

References:

  1. Instituto Nacional de Estadística e Informática (2016). “Peru en Cifras: Ayabaca, Piura” Retrieved November 04, 2016, from https://www.inei.gob.pe/.
  2. Instituto Nacional de Estadística e Informática  (2010). “Mapa del Déficit de Agua y Saneamiento Básico a Nivel Distrital, 2007”. Lima: Instituto Nacional de Estadística e Informática. Available at: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib0867/libro.pdf
  3. Garcia HH et al. (2016). “Elimination of Taenia solium Transmission in Northern Peru”. The New England Journal of Medicine. 2016 Jun 16; 374(24): 2335-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27305193

Fieldworkers trained for Community Health Perceptions work in Peru

Fieldworkers received training in data collection tools and methods before heading to the selected sites: Ayabaca and Montero, located in the region of Piura in the north of Peru. They will be conducting interviews and focus group discussions, elements of the Community Health Perceptions research component of the project. Their work will be informed by the findings of a community mapping that took place in October 2016, and will be complemented by the insights of a Ph.D. student in Social Marketing from Lugano, Switzerland, who is joining them in the field.

The fieldwork takes place in February 2017, during the rainy season and some challenges lie ahead of the team. However, the team is excited to engage with the communities.

National Policy Analysis in Peru

One of the main research outputs of COHESION consists of an analysis of global and national policies related to non-communicable (NCDs) and neglected tropical diseases (NTDs). The partners in Switzerland conducted the global policy analysis, whereas national policy analyses are in progress in Mozambique, Nepal, and Peru.

The COHESION team in Peru met on January 23rd to review the preliminary findings of their national policy analysis. Interesting perspectives were raised in relation to the Peruvian policy agenda, methodological considerations were shared and lessons learned were expressed that will be shared with the partner countries. In addition, participants spoke about potential activities that will follow once the analysis is finalized, including publications and dissemination of findings to national stakeholders.