COMMUNITY CASE MANAGEMENT AT SCALE IN

RWANDA EXPERIENCE OF THE KABEHO MWANA

(EXPANDED IMPACT) PROJECT PROJECT, 2006-2011

DISTRICTS OF GISAGARA, NYARUGURU, KIREHE, NGOMA, NYAMAGABE AND NYAMASHEKE, - REPUBLIC OF RWANDA

CONCERN WORLDWIDE INC. WITH

THE INTERNATIONAL RESCUE COMMITTEE AND WORLD RELIEF

ERIC SARRIOT & THE FINAL EVALUATION TEAM

January 26, 2012

Washington DC

Mothers, Health Workers, and Authorities in the Districts

MOH of Rwanda, particularly MCH Community Health Desk, Nutrition Desk and PNILP

USAID Child Survival and Health Grants Program, and Mission

Members of the Technical Working Group for Nutrition, Community Health and MCH

Evaluation team: - MOH members:

- Concern, the IRC and World Relief Members

EIP Logistics and Support

The “pioneers” of CCM in Rwanda

MCHIP CCM Scale-Up Study

Acknowledgments

1- Background 2- Evaluation Method 4- Findings 6- Conclusions 7- Suggestions

Outline

Background

Non Malaria Endemic

Non Malaria Endemic

Background and Context of Implementation

National Strategic Health Orientations Decentralization

Malaria Control

A Determined Community Health Approach

PBF

USAID/CSHGP Grants in Rwanda Initial Child Survival Projects – Home Based Management of Child Illness

/ Malaria (HBM)

Emphasis on ‘Scale’: Kabeho Mwana Expanded Impact – 6 Districts

Coalition of Partners

Overview of Strategic Contribution

Objectives Presentation Focus

1. Increase Access to First-Line Treatment 1.1 Expand CCM

• Scaling CCM in 6 districts

1.2 Strengthen Service Delivery • Drug Supply • Quality Improvement

• QI focused on Implementation of a C-IMCI Bulletin

1.3 Establish Performance Contracting for CHW Supervision

1.4 Support National C-IMCI Strategy

2. Increase coverage of preventive interventions

• Scaling up CHW Peer-Support & Collaboration Groups [aka Care Group] 3. Increase adoption of key family health

practices

$4,000,000 , 48%

$1,000,000 , 12%

$3,400,000 , 40%

USAID Required Match (25% of USG) Additional Funding

USAID Grant

Project Sources of Funding

District Approach

Capacity Building and Partnership at District and Sub-District Levels

Substantial investment in Human Capacity Training reinforced by coaching

Mixed-Team Field Offices Community Mobilization Quality Assurance M&E

Substantial presence and activity at Sector and Umudugudu levels

Scaling: One picture is worth…

Mixed Methods Evidence Based & Participatory

Evaluation Method

Methodology – Quantitative and Secondary Sources

KPC, Baseline (2006) and Final (2011) Health Facility Inventory (2010) CHW Rapid Assessment (2010) HIS (SisCom) service data Community Mobilization Database (2009-2011) C-IMCI Bulletin Database Community Capacity Assessment / COSA (2011) Nutrition Project Anthropometric Surveys and

Evaluation (2009-2010)

Methodology – Final Qualitative District Study

3 Teams ; 6 Districts; August 15-26, 2011 Hospital: Medical Directors, Supervisors +DHO

Health Centers: Community Health In-Charge + Titulaires

Cooperatives Cell Coordinators and CHWs Mothers seeking care at HC level

Textual data analysis

Iterative reviews; confrontation of analyses; synthesis

Central Level Consultations

Community Health Desk PNILP Nutrition Desk UNICEF MCHIP USAID School of Public Health

Conducted with Dr Laban Tsuma, MCHIP

A Methodological Challenge

Attribution? Contribution?

MOH energy c-IMCI = a moving target

Child Health Achievements

Child Sleeping Under ITN

Nota: RDHS 2005-2010; Prevalence of Fever: 26% to 16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2005-2006 2010-2011

Child Sleeping Under ITN

RDHS

KPC EIP

0%

10%

20%

30%

40%

50%

60%

70%

80%

RDHS KPC EIP

Care Seeking for Fever

2005-2006

2010-2011

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

RDHS KPC EIP

Appropriate Treatment of Fever

2005-2006

2010-2011

Appropriate Treatment / Fever

RDHS = Presumptive Treatment

EIP = Presumptive Treatment + RDT + when applicable

Control of Diarrheal Diseases

Nota: RDHS 2005-2010; Prevalence of Diarrhea: 14% and 13%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2005-2006 2010-2011

ORS for Diarrhea

RDHS

KPC EIP

19%

5%

22%

61%

33%

22%14%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Seeking treatment for diarrhea (ORT

at home, CHW or HC)

ORS use Zinc use Diarrhea treated with

both ORS and zinc

Increase feeding for

diarrhea

Management of and Care for DiarrheaKPC 2006 and 2011

2007 2011

Pneumonia / Care Seeking & Treatment

Nota: RDHS 2005-2010; Prevalence of ALRI symptoms: 17% to 4%

27%

50%

13%

63%

55%

0%

10%

20%

30%

40%

50%

60%

70%

2005-2006 2010-2011

Care Seeking for Pneumonia (and Treatment in EIP areas)

Care seeking if respiratory symptoms (RDHS)

Care seeking if respiratory symptoms (KPC EIP)

Care seeking and appropriate treatment for pneumonia (KPC EIP)

Behavior Change Indicators / Water and Hygiene

1- Expanding CCM in 6 Districts

Strategic Contributions

By the End of Project

6,168 binomes were involved through 660 CHW peer groups (“Care Groups”), 88 Sectors / 84 Health Centers in 6 Districts Robust retention of CHWs

EIP adjusted plans and strategies to align to and support national strategy

All 3 conditions considered, the districts of intervention of EIP reported 183,959 treatments to the CHD over the last 4 quarters (out of 567,981* for the country; or 32%)

* Thanks to Cathy Mugani and Erick Gajui (Community Health Desk)

CHWs as First Line Providers for PHC for the three Illnesses

45%

29%

0%2%

3%21%

Care Seeking for 226 Children <24mo Identified with Fever in Six Districts of EIP Implementation

CHW

HC

traditional healerfamily member

End of Project: • 69% of mothers ‘ever used’ a CHW • 40% of children with an illness in the past 2 weeks saw a CHW (KPC)

Overall CHW Utilization

Recent EIP Trend in Utilization of CHWs and Referrals

0

5000

10000

15000

20000

25000

30000

35000

Sum of Enfants_>6<59_mois_recu fievre Sum of Enfants_traites_diarrhee

Sum of Enfants_traites_pneumonie Sum of Referes_<5ans

Expanding CCM

Rapid scale up of CCM-contribution to national strategy Demand from districts

Ready interest in Care Groups

Partnership with and buy in from districts &health centers

High flexibility in implementation

Supervision happens; Drugs are there

Challenges in quality: Supervision sub-optimal Community drug supply

RDT effect on utilization Utilization rate questions,

notably for diarrhea care seeking

Epidemiologic trend and LOE of CHWs

+ - / ?

2- Quality of Care

Strategic Contributions

QA Achievements (beyond training, and drug supply)

Initiated Quarterly Feedback Meetings at HC level with Cell Coordinators

The “C-IMCI Bulletin” as an evolving learning tool Emphasis on Standards at HC Level Coaching role and presence of QA and M&E teams of

EIP

Context of PBF to bear in mind

a. Health Promotion and Communication b. THE ‘CARE GROUPS’* IN THE C-IMCI

ARCHITECTURE OF RWANDA

c. * CHW Peer-Support and Collaboration Groups

3- Community Mobilization

Med Dir | Community health supervisor

CHW cooperative

All CHWs [N=150-450]

Cell coordinator

CHW reports

C-IMCI, Default Model / without Care Group

Hospital

Health Center

Information & Feedback

Supervision

Sector COSA

1-2 hours motorcycle / car ride

Mayor Exec. Secretary Health in charge Social Affairs Economic affairs

District

Village

Exec. Secretary for cell Social Affairs Nat. Women’s committee

Cell 1 hour to 1 day walk; bicycle or motorcycle

1-2 hour walk between villages

Binome CHW

Maternal Health

Social affairs

Chronic diseases

CHWs

Data compilation and reporting meeting

Data compiling

and reporting meeting

Med Director Community health supervisor

CHW cooperative

All CHWs [N=150-450]

Feedback meeting Cell coordinators

Cell coordinator

C-IMCI, with Care Group

Hospital

Health Center

Information & Feedback

Supervision

Care Group = Local CHW Peer-Support & Collaboration Group

Sector COSA

1-2 hours motorcycle / car ride

Mayor Exec. Secretary Health in charge Social Affairs Economic affairs

District

Village

Exec. Secretary for cell Social Affairs Nat. Women’s committee

Cell 1 hour to 1 day walk; bicycle or motorcycle

Binome CHW

Maternal Health

Social affairs

Chronic diseases

CHWs

Assistant cell coordinator Home

Visits + Health Promotion Activities

Added Value of the Care Group

Brings all CHWs together to plan and organize: Curative and Preventive CHWs Home visits: Home Visits reached163,000 households of

children under 5 Weight monitoring sessions Other health promotion activities (campaigns, etc.)

Provides an energy multiplier for the Cell Coordinator work in reporting (and

supervision?) For the Community Health in Charge for supervision

through Feedback meetings and supervision to the CGs

Indirect Benefits of the Care Group

“Integrate” at local level the health care delivery (binomes) and health promotion activities of CHWs

Viewed as “part of” the Cooperative CHW structure on a different scale

Proximity support / social capital Joint activities & peer support to CHWs /

livelihood, agriculture, etc. Potential for peer supervision

Challenges with the Care Groups and their Evaluation

Comparison with non-EIP difficult (MCHIP?) Keep the “quality” of the CHW motivation and peer support in

any replication effort CC’s are not compensated

Substantial load of work (1 month: 17 reports & meetings identified).

Expansion of role But what to do if role is professionalized?

Supervision

Conclusions

EIP – Kabeho Mwana

Major Contribution to National Health Improvements of last 5 Years Health Outcomes 183,000 treatments in the last year Alignment and Harmonization

The coalition “worked”, internally and for the GOR Role at Central Level Came from Partnering Presence in the

Field (District and below down to Community)

Established critical building blocks for quality monitoring and performance improvement

Implemented a model for integrating the objectives of the different types of CHWs

Sustainability: Threats and Potential

“S” Words: The chicken or the egg?

Sustainability Scale

Suggestions / Recommendations

Suggestions

To KM partners; to USAID Phase out planning – from the start Replication of learning within consortium, with MOH,

Cooperatives, and CHWs

To the MOH and Community Health Stakeholders Consolidate the Fundamentals Quality of CCM The ‘Care Groups’, Feedback Meetings and the C-IMCI

infrastructure “Good enough” vs. “Perfect” Health Information Systems Synergies across sectors (Livelihood, Food Security)

Suggested Studies

I. Reanalysis of RDHS data (2005, 2007-2008, 2010)

II. Longitudinal, mixed method, whole-intervention (integrated), effectiveness and sustainability study

I. PBF II. C-IMCI III. Wanted and unwanted effects

III. Other Qualitative Studies

USAID / CSHGP Grantees: I. Early Evaluation Design

[+] disclaimer: the evaluator has direct or indirect ties with MEASURE Evaluation (UNC), MEASURE DHS (ICF), as well MCHIP (JHPIEGO).

Congratulations and Thank You