from care groups to chw peer support groups: scaling up in rwanda

Melene Kabadege, World ReliefMelanie Morrow, MCHIP/ ICF International

Care Group TAG; May 29, 2014

From Care Groups to CHW Peer Support Groups:

Scaling up in Rwanda

World Relief’s Umucyo CSP (2001-2006)

• Location: Nyamasheke District,

Western Province, Rwanda (Former Kibogora Health District)

• Total Population: 152,981 people in 29,166 HH

• Care Groups:

>2800 Volunteers in

202 Care Groups;

HH visits 2x/mo

10 HH per Volunteer

Trained by project staff

Umucyo Major Activities

• C-IMCI for 6 Interventions: – Malaria, HIV/AIDS, Nutrition and

BF, Diarrhea, Immunization, and MNC;

• Piloted and scaled up Home Based Management of Fever (e.g. CCM for suspected malaria)

• Also formed “Pastors Care Groups” from 11 church denominations

Umucyo Results – Malaria Pregnant Women Who Slept Under an ITN Last Night

0%

20%

40%

60%

80%

100%

Baseline KPC Midterm KPC Final KPC Rwanda DHS

2001 2004 2006 2005

Umucyo Project Impact: Estimated Annual Mortality Reduction using LiST

Using the Lives Saved Tool (LiST) to estimate mortality impact of the project, the annual U5 mortality rate decreased by 7 per year in the project area.

In contrast, sub-analysis of the DHS found that U5 mortality in the same region was getting worse – U5 Mortality increased by 3.4 per year.

Source: Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact. (Health Policy and Planning, 2013: 1-13. Jim Ricca, Nazo Kureshy, Karen LeBan, Debra Prosnitz, and Leo Ryan)

Kabeho Mwana Expanded Impact CSP Concern Worldwide, IRC, World Relief (2006-2011)

Location: 6 districts in Southern and Eastern Rwanda

Total Population: 1.67 Million

Project Focus: • Support to MOH Scale up of iCCM

(Diarrhea, malaria, pneumonia)• Promotion of Key Family Practices

– using Care Groups (we thought) MOH Mandate: Work only with Government CHWs

CHWs in Rwanda4 CHWs per Village at time of project

2 CHWs (Male-female ‘binome’) for iCCM1 CHW for Maternal Health (female)1 CHW for Social Affairs (male or female)

Workload: Each CHW is responsible for the entire village (60-80 HH), focused on their technical areas of specialty. Emphasis on treatment over household behaviors. Supervision: The Community Health In-Charge at the Health Center is responsible for supervision of CHWs.

Care Groups CHW Peer Support Groups

• CHWs from 2-5 neighboring villages organized into “Peer Support Groups” at cell level with up to 20 members, about half of whom were male.

• CHWs of all types were “cross-trained” in BCC, while maintaining their specialized functions

• CHWs from the same village divided up households (15-20 per CHW) to better support monthly home visits for BCC.

• 3 Project Promoters per district built capacity of CHW Cell Coordinators (elected by their peers) to help with training and supervision of groups.

Violates Care Group Criteria Peer Support Groups

CHW Peer Support Groups

CHW Group

CHW Group

CHW Group

CHW Group

Cell Coordinator

Health Facility-based In-Charge of Community Health

Slide courtesy of Jennifer Weiss, Concern Worldwide

Outputs and Impact using Peer Support Groups

• Trained 13,166 CHWS (all cadres) in 660 groups to do BCC for C-IMCI during monthly home visits and community mobilization.

• Trained over 6,100 CHWs and 88 health centers to implement iCCM

Re-analysis of the Rwanda DHS (2005-2010) found that U5 mortality rates decreased more in project districts than non project districts. (Data currently undergoing peer review for publication. )

Benefits of Umucyo Care Groups

• Afforded closer supervision • Better ratio of households per volunteer or

CHW (10 vs. 20) • More frequent home visits (2/month vs.

1/month). • Impact on household behavior was greater

but in a smaller population

Benefits of CHW Peer Support Groups in Rwanda Context

• Directly supported and improved MOH CHW system; scalable (but not nationally adopted)

• Impact was at greater scale – – 18% of country; 1.6 Million population – caveat: budget and interventions were different than Umucyo

• Helped CHWs integrate and coordinate their activities, including CCM

• Like Care Groups, contributed to CHW motivation, improved supervision, and increased social capital.

• Gender balance strengthened male involvement

Thank You