December 2012 The USAID Primary Health Care Project in Iraq (PHCPI) is funded by United States Agency for International Development (USAID) under Contract No. AID-267-C-0-11-00004. The project team includes prime recipient, URC, and sub-recipient organizations Management Sciences International and Sallyport Holdings, Inc. This publication was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID). Operational Research On Maysan Health Visitor and e-Health Program Evaluation PRIMARY HEALTH CARE PROJECT Operational Research On Maysan Health Visitor and e-Health Program Evaluation PRIMARY HEALTH CARE PROJECT December 2012 DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. CONTENTS Summary........................................................................................................................................................................1 Background ...................................................................................................................................................................2 Rationale for this study................................................................................................................................................2 Main research questions .............................................................................................................................................2 Methods .........................................................................................................................................................................3 Data from the communities on effectiveness of the program .....................................................................................3 Information from the PHCC s .......................................................................................................................................3 Data Collection ............................................................................................................................................................3 Site Selection...............................................................................................................................................................3 Sample size .................................................................................................................................................................3 Ethical Approval...........................................................................................................................................................4 Results ...........................................................................................................................................................................5 Results of community surveys.....................................................................................................................................5 Sites sampled and household characteristics.........................................................................................................5 Childhood immunization results...............................................................................................................................5 Illness in the past two weeks among persons aged five and older.........................................................................6 Patient satisfaction – persons aged five years and older ........................................................................................6 Illness in the past two weeks among children under age five .................................................................................6 Patient satisfaction – caretakers of children under age five.....................................................................................7 Obstetrical delivery in past year ..............................................................................................................................7 Child care since birth...............................................................................................................................................8 Most recent visit from a health visitor.......................................................................................................................8 Actions taken during most recent health visitor visit................................................................................................8 Household health information – smart cards ...........................................................................................................8 Perceptions of the nearest PHCC ............................................................................................................................9 Satisfaction with health visitors ................................................................................................................................9 Electronic household registration.............................................................................................................................9 Results of health facility assessments and interviews ................................................................................................9 Setting up the program ............................................................................................................................................9 Required equipment for e-health...........................................................................................................................10 Additional staff requirements for the health visitor program ..................................................................................10 Human resource commitment to health visitor program........................................................................................10 Perceptions of HV achievements ...........................................................................................................................11 Perception of community leadership .....................................................................................................................11 Challenges for the Health Visitor Program.............................................................................................................11 E-Health household registration.............................................................................................................................11 Health clinic information systems...........................................................................................................................11 Health facility workflow tabulation..........................................................................................................................12 Workflow measures reported for health visitors.....................................................................................................12 Discussion...................................................................................................................................................................13 Conclusion...................................................................................................................................................................14 Annex: GIS Photographs ...........................................................................................................................................15 Operational Research on Maysan Health Visitor and e-Health Program Evaluation 1 I n August 2012, a detailed evaluation of the Maysan health visitor and eHealth program was conducted. This program was started in 2005 and now includes all health facilities in the gover-norate. The evaluation included 250 or more households in the catchment areas of each of six Primary Health Care Clinics. Health leadership, staff and community leaders were also inter-viewed for their views. Data were collected and analyzed in Baghdad by the USAID-funded Primary Health Care Project (PHCPI). The evaluation showed a very high coverage rate for all vaccines, exceeding 95%. This was ac￾complished through household registration and frequent household visits by the health visitors working alongside community health workers. Also contributing to the success of the program was the implementation of the electronic registration system, household smartcards, and SMS text reminder messages. Our check of the households against the electronic database found no discrepancies. Coupled with this has been extensive work in improving clinical care, both in the households and in the clinic facilities. There is excellent access to health facilities when a household member is ill and a high level of satisfaction from both the users of the health system and the leaders. Putting this system in place requires extra resources, both human and technical. The major commitment is certainly personal commitment by program leadership. Without this, the achievements could not have been realized or maintained. To achieve this level of success has required many of the regular staff to work as health visitors alongside volunteers, in addition to their regular clinic roles. However this type of outreach activities is commendable and consistent with the Iraq Family Health Program model, now being implemented by the Iraqi Ministry of Health (MOH). The fact that the achievements observed in Maysan are not possible with an entirely volunteer staff should be understood and appreciated, particularly by health planners. The lessons learned from this program have important lessons for Iraq’s efforts to provide high quality care for all beginning at the household level. SUMMARY A health visitor in Maysan 2 USAID/Primary Health Care Project in Iraq Maysan governorate has a population of slightly over one million people and traditionally it is one of the poorest in Iraq.1 The 2006 MICS survey found malnutrition in Maysan to be high, even considering the regional standards of southern Iraq . About 35% of the population is rural. Lack of safe water, poor sanitation, and poor access to electricity makes it one of the poorer performing governorates in Iraq.2 Maysan also has one of the lowest rates of children attending primary schools. Starting in 2005, a pilot program began in Maysan to introduce an innovative health visitor pro-gram combined with an e-health initiative. The catchment or service area of each Primary Health Care Clinic (PHCC) was divided into units each with between 50-400 households. A PHCC-based health visitor (HV) was assigned to each unit and worked with 5-10 Community Health Workers based at the clinic. Training was provided in topics such as use of technology and communications as well the heath skills for maternal child health (MCH) care and later for non-communicable diseases, which became an area of emphasis in subsequent phases of the project. Hypertension and type 2 diabetes are conditions of specific concern. The health visitors work with community health workers in mapping and collecting household demographic and health information. These data are entered into a computer database that can be updated by health visitors. In addition, patient health care information is recorded on smart cards, and GIS tags are being linked to health records. Care for IDPs is being incorporated into the information system. Implementation started with two PHCC and with subsequent phases now involves the nearly all of the 62 PHCCs in Maysan. BACKGROUND Rationale for this study Administrative data have indicated that the Maysan program has increased immunization coverage, provided special care to high-risk mothers, and increased health care utilization, based on a comparison with baseline values. The central MOH is considering expanding this approach to other areas of Iraq. The evaluation reported here was carried out as an independent assessment of the outcomes and the resource requirements of this program. This includes information obtained from both the community and the PHCCs, and their staff, using various qualitative and quantitative methods. Main research questions 1. What are the resource requirements to initiate and to sustain the Health Visitor program for the health system? 2. What results have been achieved for the health of the community in the service areas of participating facilities and in the facilities themselves? 3. What are the perceptions of community and health system key informants about this program? 1 Figure 1 taken from MICS Survey data, 2006. 2 UN IAU Iraq Information Portal, 2012. http://www.iauiraq.org/gp/missan/default.asp Figure 1. Percentage of malnourishment in Southern Iraq, 2006 AN NAJAF AL MUTHANNA AL BASRAH MAYSAN DHI QAR AL QADISIYAH WASIT KARBALA BABIL BAGHDAD Percentage of malnourishment Scale=14% Weight for age below – 2 SD Height for age below – 2 SD Weight for height below – 2 SD Operational Research on Maysan Health Visitor and e-Health Program Evaluation 3 The evaluation focused on two areas: the health facility and what is required to support the health visitor program, and what is the impact of the Health Visitor program on the community. These two parts were further broken down into a variety of component parts, as noted below. The questions were developed, tested and modified before being selected for inclusion in the questionnaires. Data from the communities on effectiveness of the program 1. Household survey, approximately 250 per community in six areas 2. Key informant interviews with community leadership 3. Validation of electronic household records against actual household situation Information from the PHCCs 1. Interview with the PHCC in-charge 2. Interviews with other facility health workers 3. Focus group interviews with the community leadership 4. Review of the health facility functionality, including review of health facility records Data Collection There were 32 interviewers and supervisors selected. These were health staff and CHW with health backgrounds in addition to supervisors from both Maysan directorate of health including its different sectors and departments and also supervisors from Baghdad, including experienced supervisors from the MOH Preventive health department and PHCPI consultants. They were given five days of training on location in the Maysan directorate of health (DOH). The training included conducting a pilot study in both the PHCC and the community. The actual fieldwork was carried out from 1-20 August 2012. The interviewers worked individually and in pairs de-pending on the type of interviews carried out. Household interviews were conducted in pairs. Data were recorded on paper forms that were checked in the field for missing values before being brought back to Baghdad for data entry and analysis. Six separate instruments were used, and their findings incorporated into the two sections of this report. Methods Site Selection Two PHCCs were selected from the earliest phase of implementation, two from an intermediate phase and two PHCCs from an area where the health visitor program has just been more recently introduced. The original implementation plan was followed with one urban PHCC and one rural PHCC selected. Household sample size was determined to be adequate to compare between the two facilities in each implementation phase as well as among the six PHCCs (see Figure 3). Sample size The household sample size was selected based on an anticipated differenced in DPT3 coverage of at least 12% above the national UNICEF estimates for Iraq (73%) using a 95% confidence interval and an 80% power and allowing for a 5% refusal rate. The assumption was that the household would be selected using a simple random sample and not a cluster survey, which would have required an increase in number for an anticipated Design Effect. Using this ap-proach we recommended a household sample of 265 households containing a child under age five per clinic catchment area. The alternatives sampling options are included in Table 1. Surveyors conduct interviews 4 USAID/Primary Health Care Project in Iraq Ethical Approval Permission of authorities and community leaders was secured in advance. No unique identifiers were collected. Participants were read a consent form and had the opportunity to decline to participate. Figure 2. Maysan study design PHCC 1 PHCC 2 PHCC 4 PHCC 5 PHCC 6 Community 1 n=265 Community 5 n=265 Community 4 n=265 Community 3 n=265 Community 2 n=265 Community 6 n=265 Comparisons Phase 1 Phase 2 PHCC 3 Phase 3 Figure 3. Sample size needed if immunization coverage with the comparison criteria Difference between HV facilities and non HV facility Size needed at 95% confidence interval and 80% power 10% 350 12% 240 15% 151 20% 83 Based on an estimated 65% DPT3 coverage for Iraq (UNICEF) Operational Research on Maysan Health Visitor and e-Health Program Evaluation 5 The following sections detail the results of the evaluation in two main parts: the first represents the results of the HV intervention as measured through the household and community assessments; the second part looks at the establishment and internal structure of the program. Results of community surveys Sites sampled and household characteristics Table 1 below lists the PHCC catchment areas, the number of households sampled from each, and the total number of residents. The date of implementation of the health visitor program is noted and whether the facilities were central or peripheral. The average number of persons per household was eight for peripheral areas and five for central areas. Ninety-two percent (92%) of households had a child results less than five years of age. Most households had two children under the age of five years. Chronic illnesses among adults were common. Among the 1,576 households, there were 109 males and 99 females who indicated they had a chronic disease condition present. The most common conditions reported were hypertension followed by type 2 diabetes and asthma. Childhood immunization results 95.9% of children present in the sampled households have been fully immunized by age. Of the children who are fully immunized and their caregiver knows where it was done, only 258 or 16.4% received all of their immunizations at the PHCC, and the remaining 81.4% received all are part of their immunizations from the health visitors. However, levels for vitamin A administration in the past six months were much lower at 35%. These data are summarized in Tables 2 and 3. Table 1. Demographic characteristics of households Clinic catchment area HV implemented Number of Households Total household residents Male adults Female adults Male U5 Female U5 Al Adel (p) 2005 265 1,653 656 699 148 150 Al Hussein (c) 2005 264 1,413 553 601 121 138 Al Hady (c) 2006 267 1,576 639 677 151 109 Al Iskan (c) 2006 259 1,679 675 696 163 145 Al Kahlaa (p) 2009 264 1,658 659 701 151 147 Al Izeer (p) 2009 257 1,699 690 701 159 149 Total 1,576 9,678 3,872 4,075 893 838 (c) central location (p) peripheral location Table 2. Immunization status of children under age 5 Clinic catchment area Number of children U5 Fully immunized for age Not immunized Not sure All at PHCC Part by HV Not sure Al Adel 265 264 0 1 5 259 1 Al Hussein 264 260 1 3 28 233 3 Al Hady 267 248 4 15 171 87 9 Al Iskan 259 257 0 2 40 219 0 Al Kahlaa 264 251 0 13 19 243 21 Al Izeer 257 232 0 25 15 242 0 Total 1,576 1,512 5 59 258 1283 34 6 USAID/Primary Health Care Project in Iraq Illness in the past two weeks among persons aged five and older As part of the household survey, illness in the past two weeks was asked for any adult and any child living in the household. In addition the household was queried as to whether the person ill was treated in the household or taken for treatment outside the household. If they were treated outside the house, the location was noted, as was if they then went to a second location for an additional opinion or treatment. There were persons over age five who were ill in from 215 households who reported being ill in the past two week. This was an illness in 215 or 13.6 % of households. Of persons from this household about 1% did not seek treatment outside the household. There were 144 or 67% who sought treatment at the PHCC and 35 or 16.3% who visited a private doctor of clinic. Other sources were 14 (6.5%) going to the hospital, 2 (0.9%) going to the health visitor, and 15 (7.9%) consulting the pharmacy. Only one household indicated they had contacted a traditional healer. Out of the 213 households where treatment was sought out of the household for the person ill, 57 or 26.8% sought a second opinion or second treatment source. Of households with someone ill those seeking a second opinion, 30 or 52.6% sought this from the private doctor or clinic and 12 or 21% sought this from a hospital. Five or 8.8% used the pharmacy as the second treatment source. Patient satisfaction – persons aged five years and older Only the patient or those accompanying the patient during a treatment visit for the last illness were asked about satisfaction levels. A modified Likert scale was used with a four-point response scale. In Table 5, those agreeing or strongly agreeing responses are combined. Illness in the past two weeks among children under age five These same questions were asked at the household for illness under age five. Among children under age five there were persons from 251 households who reported being ill in the past two weeks, or 15.9 % of households. Of persons from these households, about 1.6% did not seek treatment outside the household. There were 208 or 83.5% who were taken for treatment at the PHCC and 27 or 10.8% who were taken to a private doctor of clinic. Other sources included 3 (1.2%) going to the hospital, one going to the health visitor, and six (2.4%) whose caretaker consulted the pharmacy. Only two households indicated they had contacted a traditional healer. Out of the 247 households where treatment was sought out of the household for the child who was ill, 79 or 31.7% were taken for a second opinion. Of households with someone ill those seeking a second opinion, 23 or 29.1%% of households sought this from the PHCC; 31 or 39.2% sought the second source of treatment from private doctor or clinic and 14 or 17.7% sought this from a hospital. seven or 8.8% used the pharmacy as the second treatment source. Table 3. Vitamin A in the past 6 months Clinic catchment area Vitamin A at PCC Vitamin A by HV No Vitamin A Not sure Total Al Adel 66 2 197 0 265 Al Hussein 98 0 130 36 264 Al Hady 64 6 186 11 267 Al Iskan 83 44 72 60 259 Al Kahlaa 47 55 127 35 264 Al Izeer 51 36 156 14 257 Total 409 143 868 156 1,567 Table 4. Illness in the past 2 weeks in persons over 5 Clinic catchment area Ill in the last 2 weeks Not ill in the last 2 weeks Al Adel 30 235 Al Hussein 22 242 Al Hady 43 224 Al Iskan 36 223 Al Kahlaa 32 232 Al Izeer 52 205 Total 215 1,361 Operational Research on Maysan Health Visitor and e-Health Program Evaluation 7 Patient satisfaction – caretakers of children under age five Only those accompanying the patient during a treatment visit for the last illness were asked about satisfaction levels. A modified Likert scale was used with a four-point response scale. In Table 7, those agreeing or strongly agreeing responses are combined. Obstetrical delivery in past year Households were asked if there had been a birth of a child to a resident of this household in the past year. There 563 households that responded positively, making 35.7% of households with a birth. Table 5. Patient satisfaction conveyed by caretakers of adults above the age of five years Clinic catchment area Number Treated with courtesy The waiting time was too long The diagnosis was explained clearly The treatment was explained clearly I had full trust in the health worker Getting medicines was easy The health facility was kept clean We were satisfied with the care received We felt the security was good at the health facility Al Adel 30 27 9 28 27 28 25 28 27 29 Al Hussein 22 20 7 20 20 20 18 20 18 21 Al Hady 43 38 8 35 34 38 37 38 37 40 Al Iskan 36 26 5 32 33 33 26 33 30 35 Al Kahlaa 32 24 4 25 25 29 28 27 28 32 Al Izeer 52 47 8 49 49 39 45 47 47 49 Total 215 182 41 189 188 187 179 173 177 196 Table 6. Illness in the past 2 weeks children under 5 Clinic catchment area Ill in the last 2 weeks Not ill in the last 2 weeks Al Adel 30 235 Al Hussein 22 242 Al Hady 43 224 Al Iskan 36 223 Al Kahlaa 32 232 Al Izeer 52 205 Total 215 1,361 Table 7. Patient satisfaction conveyed by caretakers of children under the age of five years Clinic catchment area Number Treated with courtesy The waiting time was too long The diagnosis was explained clearly The treatment was explained clearly I had full trust in the health worker Getting medicines was easy The health facility was kept clean We were satisfied with the care received We felt the security was good at the health facility Al Adel 59 52 11 53 53 55 53 53 52 55 Al Hussein 36 31 8 29 28 32 29 29 28 33 Al Hady 43 35 9 36 37 39 37 37 37 41 Al Iskan 37 31 6 32 31 33 32 33 32 35 Al Kahlaa 22 18 4 18 17 19 18 17 19 20 Al Izeer 50 41 9 43 42 45 43 43 44 46 Total 247 208 47 211 208 223 212 212 212 230 8 USAID/Primary Health Care Project in Iraq Of these births, 355 or 63.0% occurred in a public hospital, 40 or 7.1% in a PHCC (Al Adel, Al Kahlasa had 24 and 13 respectively), 91 or 15.6% at home with a skilled attendant, and 47 or 8.1% at home with a traditional attendant. There were 46 who delivered at other locations. For the cost of delivery, 68.2% of households paid 500 dinar or less. Child care since birth Households were asked where the infant had received care since delivery. The large majority, 515 or 91.5% had reported the PHCC as the source of child care with 18, or 3.2% using private doctors’ clinics and 11 or 2% using a private clinic operated by a nurse. The remainder said they did not know or used a polyclinic associated with a hospital. Table 8 shows births to household in 2011. activities were carried out. This distribution varied widely among the catchment areas of the six health PHCCs, but checking immunization status of children was reported by all households. Household health information – smart cards Smart cards are the basis of the recording keeping for the households and the health service in Maysan governorates. Households were asked if the household had its own smart card. All respondents Table 8. Births to household in past year (2011) Clinic catchment area Birth No births Total Al Adel 113 152 265 Al Hussein 89 175 264 Al Hady 92 175 267 Al Iskan 107 152 259 Al Kahlaa 66 198 264 Al Izeer 96 161 257 Total 563 1013 1,576 Figure 4. Date of the most recent visit by HV 1,600 1,400 1,200 1,000 800 600 400 200 0 1 month 2 months 6 months 5 months 4 months 3 months 7 months Figure 5. HV actions during last visit Updating HV records Environmental health check Previous clinic visit follow up Pregnancy follow up NCD follow up with resident Child’s immunization status check Checked health of children 0 200 400 600 800 1,000 1,200 1,400 1,600 Most recent visit from a health visitor To get an idea of how active the health visitors were in the community, households were asked when the last visit to their household from the health visitor was. Households reported that 87.3% had received a visit within the past month. Households in the Al Adel clinic catchment area had 100% of households visited within the past month. All other catchment areas were similar except for Al Hady catchment area, where only 42% of households had been visited within the past month. In the case of Al Hady catchment area, all households sampled had been visited in the past 7 months, but these most recent visits had been spread over the entire period (Figure 4). Actions taken during most recent health visitor visit Multiple activities were reported by the household as being carried out at each visit by the health visitor. Figure 5 shows the frequency with which specific Operational Research on Maysan Health Visitor and e-Health Program Evaluation 9 said a smart card was present in their household. They were then asked when was the last time that their card had been put into a reader by a health worker. There were 1420 or 90.1% who said this had been done in the past one or two months, and 118 or 7.5% saying between two and six months. This leaves only 38 households or 2.4% saying that the card was last read beyond six months or never. Perceptions of the nearest PHCC The head of the households or senior household member was asked if they knew the nearest PHSS well enough to make comments on the care this facility has a reputation of providing. Table 9 indicates the percentage of respondents who had a positive or strongly positive response. Satisfaction with health visitors The households were also asked about their attitudes to the health visitors. Less than 1% of households did not believe that the health volunteers had been a benefit to their households. When asked from a community perspective, more than 99% of respondents stated that the health volunteers had made a change in their community. Table 9. Perceptions of nearest PHCC Clinic catchment area The hours of the clinic are not convenient The doctors and nurses treat patients with courtesy The waiting time was too long Health workers have time to explain your condition Needed equipment is in working order I had full trust in the health worker Medicines were usually available The health facility was kept clean We felt the security was good at the health facility There are enough female health workers My neighbors are satisfied with the clinic Al Adel 100% 100% 15.5% 100% 100% 98.9% 92.1% 100% 100% 99.6% 99.6% Al Hussein 99.6% 98.5% 19.7% 99.2% 99.2% 99.2% 85.2% 98.5% 100% 87.9% 99.6% Al Hady 94.0% 93.2% 27.9% 99.3% 95.1% 92.5% 94.4% 94.0% 100% 86.8% 94.0% Al Iskan 97.7% 96.1% 6.2% 98.1% 98.1% 98.8% 96.9% 97.3% 100% 96.5% 96.9% Al Kahlaa 98.5% 97.7% 36.7% 98.9% 99.0% 95.8% 90.5% 97.3% 100% 87.5% 98.9% Al Izeer 95.3% 96.5% 14.4% 94.6% 94.6% 84.1% 92.6% 96.1% 100% 67.3% 94.6% Total 97.5% 97.0% 20.5% 98.8% 97.3% 94.1% 91.9% 96.5% 100% 87.6% 96.6% Electronic household registration In four of the six clinic catchment areas 10 households were sampled at random and the electronic data were compared with actual household data. In all 40 of the households selected the electronic data and the household data were identical. Results of health facility assessments and interviews Six PHCC Directors were interviewed. All six were medical doctors. Two had been in their position less than 5 years. Four had been present when the program started. In addition, 43 facility health workers were interviewed. They headed clinics that employed from 3 to 48 health worker staff, with an average of 28 staff. Focus group discussions were also held with community leaders. Setting up the program In setting up the program a number of steps were seen as crucial by all six of the clinical direc-tors. This was echoed by the health facility staff. In all cases the implementation of the health visitor and eHealth program coincided with renovation of the health facility. 10 USAID/Primary Health Care Project in Iraq Other activities that were conducted at the beginning of the program included: • Training of health staff • Training of health staff for all aspects of the program • Geographical mapping of the communities • Mobilizing community for participation • Collecting and electronically entering community data • Converting health facility patient records to a digital format and starting to use these Required equipment for e-health To begin the e-health component of the program, certain equipment was required, including: • Laptops • Internal clinic intranet network • Connection to an external internet work (seen as important by four of the six clinical di-rectors) • GPS units were central to the program • GIS systems and maps were an integral part of the program • Smart card equipment • Mobile health SMS applications Additional staff requirements for the health visitor program While four of the six directors indicated that additional staff was necessary to start up the pro-gram, two did not take on additional staff. Of those taking on additional staff, one clinic took on eight staff, two took on four and one took on two staff. Training provided was less than one week, however annual refresher training workshops and on the job training was provided. The health facilities indicated that there are currently 43 health visitors working from the six facilities, a range for 3-12 across the PHCCs. Supervision was provided by various persons including the PHCC manager, the district manager, and the DOH manager. Conditions that the Health visitors are trained to participate in treatment include: • Hypertension, diabetes and asthma • Respiratory symptoms • Gastrointestinal problems • Assist those with special needs • Assist the PHCCs in achieving full immunization programs • Follow up pregnancies with household checks for anemia • Screening and awareness for NCDs and early detection of breast cancer • Routine water quality examination Equipment and supplies that the HVs carry with them include vaccine cool boxes, health infor-mation materials, blood pressure cuff, and blood glucometer. Human resource commitment to health visitor program When the information from the clinic professional staff interviewed was added to that of the clinic directors a more comprehensive picture of the program’s activities emerged. Across the six facilities there were 60 health visitors working full-time and 31 working part-time. One PHCC had no full-time staff, but 13 part-time staff. Travel for the health visitors program ranged from 40 to 375 km per week, averaging 207 km per week. Four of the five PHCC units deployed their own clinical staff to work as health visitors in the community in addition to the volunteer staff. In the catchment areas from five facilities individual clinic staff spend anywhere from 10-20 hours a week in health visitor A health visitor measures the blood pressure of a community member Operational Research on Maysan Health Visitor and e-Health Program Evaluation 11 work. In addition, five of the six health facilities have community health workers and maintain regular training programs for them. PHCC staff estimated that among the six facilities there were 43 hours a week spent by clinic staff doing health visitor work in the community. In addition to the health visitors, there were a total of 43 community health workers counted by the clinical staff across the six facilities. Perceptions of HV achievements All clinic directors thought the health visitor program had reduced morbidity and mortality in their clinic catchment areas and improved NCD control. They believed the program improved the relationship between the community and the PHCC, and facilitated utilization of the health facilities by the community. The clinical staff agreed with the directors in this. They saw the program as building community participation and supporting more constructive health behaviors. The facility staff was very supportive of the health visitor program. Perception of community leadership The community leaders participating in discussion on the health visitor program agreed that the health visitor program strengthened the links between the health facilities and the civil society sectors. The community reiterated its involvement in the health visitor scheme and that the community had benefited. At the same time they noted that this program had strengthened the quality of the PHCC services. There was a worry on the part of the community leaders that some people in the community were not benefiting fully from these advances. Also there was some concern about the potential use of household data collected. Challenges for the Health Visitor Program Intermittent electricity is a major problem identified by all interviewed as well as the shortage of human resources for the program. Additional human resources are needed to help manage the digital components. In all there were 17 additional IT staff working to maintain the health visitor and eHealth programs. Regular updating of the records is needed by the program, which takes some time. The clinical staff estimated that between 3 and 12 hours a week were required for the updating records, depending on the facility and the workload. The eHealth digital program is seen to be lacking in policies and protocols to standardize its use in Iraq. The community as well lacks a good understanding of eHealth resources and how these are being used for their benefit. E-Health household registration This activity has been phased in at two-year intervals from 2005-2009. The first function was the creation of the household electronic registration system. The directors saw many of the same benefits from the eHealth program as they did for the health visitor program—reduced morbidity and mortality and an improved community awareness about disease as well as better links with the community. Specifically, directors saw a role in helping community members with NCDs control their conditions and also building preparedness for health emergencies. The same challenges that affected the health visitor programs such as electricity and shortage of human resources also were seen by the directors as affecting the eHealth program. While community leaders in general saw this as a positive program, some were concerned about potential adverse effects of registration, perhaps about the collecting and availability of personal information. All community leaders indicated that the registration teams had been to their own households. Community informants from among community leaders were well versed in the eHealth registration system and its application. Health clinic information systems The directors indicated that implementation of this program in 2005 at all sites was started with support from the DoH and directed at using technology to solve health concerns. The SMS technology was seen by all as a great addition to the health program in the governorate. Additional financial resources were available. Additional support from local and international NGOs and technological assistance was A health visitor measures provide vaccination to a child 12 USAID/Primary Health Care Project in Iraq provided. Initial training and subsequent refresher courses have been held. All sites indicated that between 2 and 10 hours a week additional time was required to maintain the system. Smart cards used for routine health records in all sites, and the four of the six sites smart cards are used for maternity records. All sites indicated the need for training, and the lack of awareness in communities of information technology. Health facility workflow tabulation Data were collected on health facility activities that may have been affected in various ways by the introduction of the health visitor program. These are set out in Table 10. Table 10. Key PHCC workflow measures before the HV program was started, the following year and for 2011 Indicator Al Adel Al Hussein Al Kahlasa Al Izeer Al Iskan Al Hady Year HV program started 2005 2005 2006 2006 2009 2009 Baseline New U5 Visits 4,728 2,045 9,378 5,654 5,920 9,470 1 Year New U5 Visits 5,613 3,909 13,051 8,954 9,023 17,023 2011 New U5 Visits 15,099 11,132 12,262 10,421 8,752 26,514 Baseline New Over 5 Visits 13,567 38,917 19,532 24,400 39,247 36,890 1 Year New Over 5 Visits 16,456 38,930 42,655 24,048 64,198 41,529 2011 New Over 5 Visits 39,472 45,777 51,938 27,293 8,752 45,290 Baseline ANC Visits 1,764 966 2,504 3,528 1,352 662 1 Year ANC Visits 2,031 1,575 2,707 1,776 1,923 1,026 2011 ANC Visits 3,010 5,294 5,089 4,359 1,988 2,380 Baseline Immunizations 1,271 3,587 15,844 1,171 9,219 572 1 Year Immunizations 19,825 5,209 18,002 20,424 10,330 7,216 2011 Immunizations 6,012 8,258 19,577 8,375 8,658 7,833 Table 11. Health visitor household visits Indicator Al Adel Al Hussein Al Kahlasa Al Izeer Al Iskan Al Hady Year 1 Household Visits 50,000 5,184 2,160 3,622 0 11,234 2011 Household Visits 28,880 960 528 4,850 26,450 2,400 Year 1 Exams of Under 5S 2,850 3,872 13,551 5,720 7,920 11,264 2011 Exams of Under 5S 3,070 1,523 8,550 12,600 15,840 2,400 Year 1 Exams of Over 5S 4,100 10,368 17,600 6,720 39,600 0 2011 Exams of Over 5S 5,400 2,968 1,584 4,200 3,960 0 Year 1 Immunizations Given 3180 3,587 16,518 2,500 31,680 5,043 2011 Immunizations Given 115,566 3,191 6,672 0 15,840 7,833 Workflow measures reported for health visitors Table 11 shows the number of activities with the community in the first year of the heath visitors program and for the same activity in 2011. Operational Research on Maysan Health Visitor and e-Health Program Evaluation 13 T he health visitor program and its associated use of electronic data and household registration in Maysan, one of the more disadvantaged areas of Iraq, has attracted considerable attention. The results posted from a number of indicators measured have given rise to the thought that this model could be implemented elsewhere in Iraq, which would provide support to the family health care model, now seen as the basis of health services in Iraq. This independent evaluation set out to corroborate these findings and to understand the various actions that were taken in the implementation of the program. Perhaps most striking finding is the almost complete immunization coverage for age among children under age five. This is not the result of repeated campaigns but careful household cen-sus data and consistent attention to the demographic changes ongoing in the communities. This is perhaps the greatest accomplishment of the program. There are very few places where this has been achieved, certainly not in countries with as many health barriers as Iraq. The majority of the immunization program was done in the community facilitated by the health volunteers. Clearly the SMS reminder technology has played an important role in this. By contrast, coverage with vitamin A was incomplete, but this could be corrected easily with the mechanisms in place. The extensive preparatory work in developing the electronic record keeping and the smart card application for health records has made this achievement possible. This required extensive planning and a consistent approach in implementation. Fortunately, Maysan had these human resources and support from the community and the Maysan Directorate of Health. Without these, it is doubtful that this very successful program could be duplicated elsewhere. Clearly, there were increased needs both in the start-up and maintenance phase which would be required in other places as well, and these will be considered later in the discussion. Illness in the past two weeks is much at the level that one would anticipate, though figures could be higher during other seasons. What is impressive is that there were essentially no barriers to access for health services, either for children or adults. While almost all persons requiring outpatient services consulted the PHCC as a first choice, this could be taken as a manifestation of the close link between the community and the primary discussion health care facilities, or it could reflect the relatively small number of private clinics in the area. When second opinions were deemed necessary, as they were in 28% of persons over age five or 31.7% of persons under age five, the majority of second opinions came from the private clinics. Although patients and caregivers rated their trust in the PHCC has high, it is clear from this relatively high rate of a desire for a second opinion, that this trust is not absolute. The general favorable perception of the PHCC facilities is very high. About a fifth of persons thought they waited too long to be seen by a health worker, a common grumble in most health facilities. There were about 13% that expressed concern that there were insufficient female health workers to provide care to women. This is a potential barrier that could be addressed. The relatively high rates of fertility are manifest with35.7% of households having a delivery in the past year. All but 47 of the 576 deliveries were with a skilled birth attendant. This 8.7% using traditional birth attendants shows there is still room for improvement. As dramatic changes have occurred in the under-five mortality in Iraq, the majority of deaths are now shifted to the infant and newborn period. The health visitor program with its careful attention to household conditions and demographic events is able to play an important role in the potential reduction of deaths in this age group. An increasingly important role for the health visitors and the health system in general is the treatment and control of NCDs. The demographic and epidemiological transition in Iraq now means this is one of the major challenges facing the health status of Iraqis, both in urban and rural areas. The health visitors have the basic equipment and knowledge to manage conditions such as hypertension and type two diabetes as the frontline for the formal health sector. With risk factors for these conditions, including smoking, lack of exercise, obesity and poor diet, per￾sisting throughout Iraq, the health volunteers represent a potent force for health promotion. Health volunteers also address additional risk factors such as poor water and sanitation, which plagues much of Iraq. The survey data reflect the fact that the health volunteers do visit households regularly, as the vast majority of households have been visited within the last month. Community leadership is unanimous in its support of the positive effects this program has had. 14 USAID/Primary Health Care Project in Iraq The use of electronic records has been thoroughly implemented using smart cards, computerized systems in clinics and smart card readers. All members of the selected households responded that they had these, and that they had been read and updated at their last clinic visit. In a random check of 40 households in the survey area, all data on the card were found to be accurate and up-to-date. In interviews with the health workers and clinic directors, there was a uniform perception that the health visitor program and the attendant electronic record system had reduced morbidity and mortality in the community. The community leaders interviewed also expressed this opinion. There were concerns from the health facilities that the community did not have a solid understanding about the digital record system, and in fact, that the MOH policies did not adequately support this approach. Some community members expressed concern about the extensive recording of household information by the health volunteers, and this is understandable given Iraqi’s recent history. From the project standpoint, there are initial costs for implementing this program. Some of this consists of software and hardware. GIS mapping needs to be secured, and an adequate skill base built to use this. Computers need to be acquired (in this case, laptops), and the appropriate software developed or adapted. Furthermore, there are sustained costs in time and personnel to keep this system functioning. Indeed, all facilities did have additional information technology personnel to support the programs. With time additional software updates will be required and equipment will need replacement. Of concern when thinking of expanding this to other locations in Iraq is that although the pro-gram is identified as a volunteer program, it does in fact depend on regularly employed clinical staff spending much of their time in the communities carrying out routine program activities. These are supplemented by volunteers and community health workers, but this is not an entirely volunteer program. This emphasizes what many have felt for many years: a strong community outreach program depends on a committed employed work force with major and sustained changes not achievable with an entirely volunteer community workforce. However, the CHWs continue to play an important role alongside the health visitors, whether these visitors are volunteers or not. Should the MOH look to scaling up this approach to a national program, and there is much to recommend this action, then the creation of a community workforce as regular staff, who can provide treatment and promote health should be considered. Maysan has demonstrated these benefits. The Maysan health visitor program has made very remarkable achievements, particularly in the area of child health, and is widely supported by the community, local leaders and the PHCC health staff. The electronic record system, with SMS linked technology, is another notable achievement, and worth replication in other locations. This too has its initial and continued costs. It should be recognized that while volunteers and community health workers have played a very important part in this program, the use of regular health facility employees working in the community are necessary for its continued success. conclusion Operational Research on Maysan Health Visitor and e-Health Program Evaluation 15 Annex: GIS Photog raphs 16 USAID/Primary Health Care Project in Iraq University Research Co., LLC Iraq/Baghdad • 601 Al-Mansour 26/1 Al-Ameerat Street 15 www.urc-chs.com • http://phciraq.org