In the face of many obstacles, Nicaragua’s history in ensuring a national deworming program has shed light on the potential for success.  Former Global Network intern, Frankie Lucien, and fellow George Washington University Masters student Cara Janusz, traveled to Nicaragua and investigated the challenges and achievements of the Nicaragua experience and developed a case study with support from Children Without Worms.

This week End the Neglect is featuring a six-part series of blog posts covering interesting elements of the Nicaragua experience highlighted in the case study, entitled “Worms and WASH(ED)”.

Ensuring access to treatment for intestinal parasites requires coordination of donors, governments, and organizations at all levels. One critical factor in this is integration. The integration of health programs can have many benefits over vertical stand-alone programs. Integration can be more cost-effective, and can lead to savings in financial and personnel costs.

So what exactly is integration? Many times, there are partnerships, funding, or programs for a single disease. Integration involves combining these programs to improve delivery to those who need them with the resources and commitments that are already in place. In the paper by Grépin and Reich, integration can involve joining certain activities or policy functions of different programs together, merging these programs or creating a new organization. Beyond integration of the seven NTDs, integration can also be seen by combining NTD interventions with other public health programs.

In the case of Nicaragua, deworming efforts have been incorporated into the Ministry of Health’s National Immunization Campaign (EPI). Once a year, mebendazole is given to children along with vaccinations and vitamin A supplements through schools, health posts, and later “mop up” campaigns to cover non-enrolled school-age children. Program integration makes sense as their targets are interconnected. For example, mass drug administration of intestinal parasites is combined with hygiene programs such as WASH (water, sanitation, and hygiene education) and Escuelas Saludables in Nicaragua. Deworming efforts paired with education on proper hygiene practices and clean water promotes a sustainable solution to tackling both issues at the same time.

Integration, however, is not perfect. The partnership between the Ministry of Health (MINSA) and Children Without Worms has led to covering 87 percent of school-age children with treatment for intestinal worms in 2010, which surpasses the WHO coverage target of 75 percent. There are other NGOs, as was described in an earlier part of this series, that donate drugs separately, and a lack of communication between these NGOs and the MINSA makes tracking drug administration difficult in parts of the country. For example, children under five should be provided with chewable tablets of mebendazole for safer administration. However, there is no way of tracking if they received these particular types of tablets, and, as the case study points, teachers in Leon reported that children as young as three were receiving the non-chewable forms of the drug. It was also unclear as to where the tablets came from. Other logistical challenges arise in unforeseen situations because two programs coming together bring different experiences. When mebendazole was administered  through the immunization campaign, neither water nor cups were provided for children to take the tablets.  As the program expands and works out the kinks in combining these two campaigns, detailed coordination to ensure the proper distribution of the drugs and improve logistics will be key.

In the long run, integration is a sustainable method for leveraging existing health programs in developing nations to address synergistic public health challenges.  In reality, however, there are glitches and nuances in the system, which take time to work out. Getting all the puzzle pieces to the table is only part of the challenge; the puzzle pieces must then all fit together to fully cover the target population, leaving no gaps.

 

To read more about the case study “Worms and WASH(ED)” please click here.

 

In the face of many obstacles, Nicaragua’s history in ensuring a national deworming program has shed light on the potential for success.  Former Global Network intern, Frankie Lucien, and fellow George Washington University Masters student Cara Janusz, traveled to Nicaragua and investigated the challenges and achievements of the Nicaragua experience and developed a case study with support from Children Without Worms.

This week End the Neglect will be featuring a six-part series of blog posts covering interesting elements of the Nicaragua experience highlighted in the case study, entitled “Worms and WASH(ED)”.

As mentioned in previous posts in this series, Nicaragua has had great success in reaching children with the deworming medicines they need to be free of intestinal worm infections and to live more healthy, productive lives. The country has surpassed the World Health Organization’s mandate to reach at least 75 percent of school-aged children with regular deworming treatment, actually achieving 87 percent coverage in 2010.

However like many countries in the region, Nicaragua lacks a strong monitoring and evaluation (M&E) framework to confirm the effectiveness of deworming programs in reducing the disease burden of STH infections. How well is high treatment coverage keeping kids from getting worms or decreasing the number of worms? In what regions are more or less resources needed to best sustain effectiveness of treatment programs? Unlike other developing regions, Latin America and the Caribbean (LAC) has not carried out extensive mapping of STH infections and thus has no baseline to measure success or identify gaps.

M&E is identified in the case study as the “lynchpin of sustainability and effectiveness of deworming efforts in Nicaragua and the broader region”. Sustainability and possibly disease elimination will require increased country ownership to scale-up deworming activities and enact long-term preventative measures such as WASH(ED), but the kind of financial support needed for those kinds of changes depends on real impact numbers.

The good news in Nicaragua is that progress is being made to ramp up M&E efforts, and in some cases Nicaragua is serving as a leader in the region. In 2011 Nicaragua launched new immunization cards which include a category for deworming treatment. This program is unique to Nicaragua and will hopefully lead to more successful M&E programs throughout the region. Additionally, guidelines were developed in 2010 for projects funded by the LAC NTD Initiative- a partnership between the Pan American Health Organization, the Inter-American Development Bank and the Global Network- to help standardize M&E activities and to find ways to incorporate data collection and disease surveillance into existing programs. The local PAHO office is looking at these and other opportunities to support the ministry in continue building M&E activities.

In the face of many obstacles, Nicaragua’s history in ensuring a national deworming program has shed light on the potential for success.  Former Global Network intern, Frankie Lucien, and fellow George Washington University Masters student Cara Janusz, traveled to Nicaragua and investigated the challenges and achievements of the Nicaragua experience and developed a case study with support from Children Without Worms.

This week End the Neglect will be featuring a six-part series of blog posts covering interesting elements of the Nicaragua experience highlighted in the case study, entitled “Worms and WASH(ED)”.

Nicaragua is one of many countries around the world that has found success in implementing water, sanitation and hygiene (WASH) initiatives in schools as a way to effectively change behavior to improve disease prevention.

As documented throughout this series, lack of access to clean water and good hygiene is a risk factor for the development of neglected tropical diseases, particularly intestinal worm infections, which are very common in children.

In Nicaragua, a successful model for improvement to school sanitation and hygiene has been through the Escuelas Saludables program, a UNICEF model with more than 10 years of history in Nicaragua.  The program emphasizes hand washing, hygiene education and nutrition as a part of a school-based health program.  Specifically, this means separated sanitation facilities, trash receptacles, and clean water for drinking and hand washing.

This is crucial because, as the case study “Worms and WASH(ED)” noted, “A sizeable percentage of Nicaragua’s school-aged child population depends on schools to meet their sanitation needs because they otherwise lack access to clean water in their homes.”

The success and longevity of Escuelas Saludables hinges on support from UNICEF, the Pan-American Health Organization (PAHO/WHO)  and a mix of national and local governments and NGO partners – including the Ministry of Health, Ministry of Education and the Nicaraguan Water and Sewer Enterprise.

Support and contributions from the local community have been another necessary component to this program.  Local committees are convened that include representatives from the Ministries, local officials, and other organizations such as parent associations from schools.

The program has achieved considerable success and the ability to grow over time, both in size and scope.  It started with just 17 primary schools with a strict focus on improving water and sanitation, but has expanded to more than 350 schools and is a comprehensive model that includes school nutrition and much more, according to a report by UNICEF.

To read more about the case study “Worms and WASH(ED)” please click here.