Community Health Workers – Overcoming Scalability Challenges

The Rwanda Expanded Impact Child Survival Project Experience

Presented by:Jennifer Weiss, MPH

Health Advisor, Concern WorldwideCORE Fall Meeting 2011

Project Overview

• Implemented from 2007 – 2011 in six districts in Rwanda

• Target population: 300,000 children under five

• Technical interventions: malaria, diarrhea, pneumonia

Project OverviewGoal: Reduce child mortality in six districts in Rwanda

Objective 1: Increase

access to first line treatment

Objective 2: Increase

coverage of preventative interventions

Objective 3: Increase

adoption of key family health

practices

Illustrative Activities:

• Expand CCM• Strengthen

service delivery (QI)

Illustrative Activities:

• Support health communication campaigns and National Health days

Illustrative Activities:

• Community mobilization

• Adapted Care Group model

Integrated Nutrition - CMAM

Rwanda MOH Community Health StructureDistrict Hospital: Community Health Supervisor

Health Facility: In-Charge of Community Health

CHW Cooperative and Cell-Coordinators

Village Level: 2 ‘binomes’ for c-IMI; 1 CHW for Maternal Health, and 1 Social Affairs Officer

40-80 Villages

Cell

Cell coordinator

In-charge Community Health

1 hour to 1 day walk

Existing Supervision and Reporting Structures

Sector

Opportunities for Improvement

• MOH has clearly defined Community Health structure that includes CHWs

• CHWs are officially recognized in the community, motivated, and provided incentives (Cooperatives)

• But …– Not well geared towards effective behavior change– Challenging reporting and supervision structures

Rwanda EIP Response (as it evolved)

World Relief CSP (2001-2006) used Care Group Model

WR began to incorporate Care Groups into EIP

(2007) under Community Mobilization activities

Rwanda MOH requirements on

limited number of CHWs per village

(2008)

15-20 member “Peer Support and

Collaboration Groups” formed

with 4 CHWs from each village (2009

– 2011)

CHW peer support groups no longer fit Care Group criteria but still maintains group solidarity, and responsibility for HH visits and behavior change

EIP Community Health Structure

In-Charge Community Health

Cell Coordinator

CHW Group

CHW Group

CHW Group

CHW Group

Outputs

• 660 peer support groups formed with 13,166 CHWs in 6 districts

• Average of 163,000 households visited on a monthly basis with key prevention messages

Results

• CHW Peer Support Group activities associated with:– Four-fold increase in the

number of households with kitchen gardens

– Twenty-five fold increase in the number of households with hand washing stations

Results• Statistically significant

increases in key behavior change indicators:– Hand washing – Point of use water treatment– Care seeking for and access

to malaria and pneumonia treatment

– Immunization, and Vitamin A

• Even with main project focus on CMM!

Outcomes – Supervision and Reporting

• Peer supervision helped to compensate for health facility staff challenges (HR, transport)

• Monthly meetings provided opportunity for facilitated supervision from In-Charge Community Health or Cell Coordinator

• Reporting burden on Cell Coordinator greatly reduced

Outcomes – CHW Activities

• Provided CHWs with greater social support (small groups vs. large cooperatives)

• Groups perceived as motivating factor– IGAs

• Home visits provided mechanism for BCC that previously did not exist

• Home visits also increased contact with families and provided opportunities for referrals and follow-up CCM care

Outcomes – Integration with MOH

• MOH stakeholders, CHWs, and beneficiaries viewed CHW peer support model as part of MOH-endorsed, cell-level CHW Cooperative structure at a smaller scale

Conclusions• CHWs working as group:– Provide greater peer support through social cohesion– Encourage joint problem solving– (In Rwanda), provide mechanism for BCC and home

visits that would not exist otherwise• Scale – working at district level first, in

collaboration with TWGs – Decentralization – districts chose to adopt– Transition to country ownership

• Sub-group cooperatives for IGAs that look very similar to “CHW peer support groups”?

Conclusions

• The CHW Peer Supervision Model provides a scalable model for meaningful engagement of CHWs at the village level - where it counts!