ChildFund International

Operations Research Review: Evaluation of a community-based MNCHN innovation in rural

Honduras

Presentation:David Shanklin, MSCSGHP Operations Research Findings: Studying Systems for Community HealthCORE Group Global Health Practitioner ConferenceMay 5 – 9, 2014Silver Spring, MD

Problems CSHGP project addressed

Inequitable access to basic MNCHN care:• Inadequate health service coverage for the CSP

population in a rural zone in Honduras:– Health facilities (HFs) over 1 hour walk for large

proportion of the target population– Existing HFs have limited and and/or unavailable

staff, limited hours of operation, frequent stock outs, poor client treatment, limited staff training and supervisory support, and poor quality care

• High out-of pocket costs of accessing existing services for client families

Project goal and objectives

The goal of the CSP was to decrease maternal, neonatal, infant and under-five child mortality in the project area to levels established by the GOH, in harmony with the MDGs.

The CSP had three objectives:

1. Strengthen facility-based maternal and child health services, improving quality and demand; 2. Systemize a CB model of maternal, neonatal, and child

health and nutrition (MNCHN) services, improving equity and quality; and

3. Document, disseminate, and promote improved CB MNCHN services, standards and norms within the national decentralization strategy, improving sustainability.

Development Hypothesis

A community-based model of integrated basic MNCHN services (community volunteers working from a local physical structure applying quality improvement practices) linked to the Honduras national health system’s decentralization strategy will improve health equity among rural, low income beneficiaries by lowering barriers to access, cost and use.

Three Community-based Innovations

1. Define and standardize the role of communities in order to increase institutional deliveries and strengthen CB obstetric and neonatal care within a national decentralization strategy;

2. Create self-sustaining CB health units (UCOS) which integrate vertical MOH MNCHN programs and various cadres of community volunteers; and

3. Adapt and implement CB continuous quality improvement (CQI) systems for UCOS.

What is UCOS?UCOS are small freestanding structures located in selected communities, equipped with essential drugs, basic equipment and health education materials. Community volunteers offer care, attention, and education to persons in need, with an emphasis on women, infants and children. They are self-sustaining financially, managed by the community, supervised by the MOH, and given technical and logistical support by ChildFund Honduras. UCOS sustainability depends upon a functioning revolving drug fund.

Target population

The project was located in 12 southern municipalities of the Department of Francisco Morazán, which includes 293 communities.

Infants: 0-11 months 2,569

Children: 12-23 months 4,071Children: 25-59 months 7,933Total Children: 0-59 months 14,573 Women: 15-49 years

26,454

Total Target Population

41,027

GPS Mapping ProcessPartners:• MOH, representatives of local government, civil

society organizations and local beneficiaries

Criteria for UCOS location selection:• Existing health service locations, population

density, transportation routes and access, community interest and resources, and political support

Purpose of Operations Research

Evaluate changes in 16 indicators (dependent variables) related with UCOS service coverage, outcomes and costs.

OR Methods:• Pre-test/post-test LQAS KPCs, no comparison groups• Review of linked program data from UCOS sites• Cost study, with comparison group• FGD and interviews for qualitative information

Analysis:• Chi square analysis was used to compare baseline –

endline differences in coverage and outcome variables

Six Coverage Indicators

1) proportion of the project’s target population directly served by an UCOS; 2) pregnant women registered; 3) pregnant women with delivery plan; 4) children under age two weighed during the last month; 5) neonates visited by a skilled worker within 3 days of birth; and 6) percent of visits to families with high risk factors.

Six Outcome Indicators

1) pregnant women with at least 5 prenatal check-ups;

2) maternal or child complications with effective referral;

3) children under 5 who receive treatment according to norms;

4) children under 5 with pneumonia who receive treatment according to norms;

5) children under 5 with diarrhea who receive treatment according to norms; and

6) children under two with low weight for age.

Four Cost Indicators

1) normal delivery cost at maternal and child health clinic;

2) normal delivery cost at home; 3) cost of child care at health facility; and 4) cost of child care at UCOS.

Six Coverage Indicator ResultsVariable Baseline % Endline % X2 Sig.

Proportion of target population directly served by UCOS sites

1.4%

21% <.0001

Women’s last pregnancy registered

32% 96% 15.6 <.0001

Women had a delivery plan for last pregnancy

11% 23% 9.8 <.0001

Children under age two weighed in last month

91% 76% 11.2 <.0001

Neonates visited within 3 days of birth

31% 62% <.0001

Families with high risk factors visited*

0% 25% 54.9 < .0001

Six Outcome IndicatorsVariable Baseline

%Endline

%X2 Sig.

Women made at least 5 prenatal visits during last pregnancy

48% 68% 9.8 < .0001

Women or children with complications provided with a referral

21% 31% 0.8 < 0.4

Children < 5 treated according to norms

14% 38.1%

27.7 < 0.001

Children < 5 with pneumonia treated according to norms

50% 100% 126.7 < 0.002

Children < 5 with diarrhea treated according to norms

50% 50% 0.17 < 0.7

Children < 2 with low weight for age

31% 28% 0.5 < 0.5

Selected additional maternal and neonatal outcomes indicators

• Delivered at a health facility (71% to 81%)• Immediately breastfed at birth (44% to 70.5%)• Knew the danger signs of newborn infants (7.4% to 44.2%)

and sought care (15.0 % to 85.7%)• Received postpartum care within seven days (39.2% to

74.7%)• Received neonatal care within seven days (59.1 % to 66.7%)• Received a home visit by qualified health personnel (from

13.7% to 73.8%)• Proportion of both partners (women and men) who

participated in health care decision making (6.3% to 26.3%)

Selected additional child outcome indicators:

Mothers took their children to a health provider within 24 hours of onset when they recognized danger signs of common childhood illnesses:

• Diarrhea (from 5.3% to 33.3%)• Pneumonia (from 4.4% to 25.0%)

Child mortality rate trend in the project area (but without a comparison group)

Cost of delivery according to the level of attention and funding source

Service Delivery Level Institutional cost

Out-of-pocket cost

TotalLimpera

TotalUSD

Community (trained midwife) L. 13.00 L. 600.00 L. 613.00 $ 29.96

Materno-Infantil Clinic L. 4,760.72 L 1,130.00 L. 5,957.00 $ 291.15

San Felipe Hospital L. 7,301.63 L 2,180.00 L. 9,481.00 $463.39

Materno Infantil Hospital L. 9,492.00 L 1,680.00 L. 11,172.00 $ 546.84

Private Hospital NA L 23,000.00 L 23,000.00 $ 1,124.14

Exchan rate: 1$ = L. 20.46

Cost of the care of an under five year old according to the level of attention

Service Delivery Level Institutional Cost

Out of pocket

expenses

% TotalLimpera

TotalUSD

UCOS L. 29.78 L. 34.00 53% L. 63.78 $ 3.11

CESAR L. 128.46 L. 122.00 49% L251.58 $ 12.29

CESAMO L. 225.98 L. 162.00 42% L. 389.00 $ 16.56

Government Hospital L. 765.44 L. 686.74 47% L 1,457 $ 71.21

Summary of average cost differentials

• Average out-of-pocket costs for a family who sought health services at a health post with an auxiliary nurse rather than an UCOS was 4 times more, at a health clinic with a doctor it was 6 times more, and at a hospital with a medical team it was 23 times more.

• The average of cost an UCOS visit was USD $8.18. • Giving birth in the maternity clinic was 60%

cheaper than in a governmental hospital.

Additional results of MCHIP Equity Study

Client satisfaction was high with services received

Mothers and CHVs participating in final evaluation focus groups mentioned:

• “The CHVs at the UCOS are always worried about us”• “We do not have to walk very far to get a medicine”• “We want to participate and support the CHVs

because they work without payment”• “I am happy because (at the UCOS) I always find

help”

Summary of OR Study Findings

Of 16 indicators used to track progress:• Six of 6 coverage indicators improved• Three of 6 outcome indicators significantly improved,

and selected other outcome indicators indicated clear improvements

• Costs to clients were dramatically reduced, and the poorest of the poor were reached through UCOS services

Conclusion:CB health units linked to MOH programs and existing health facilities provide less expensive, responsive MNCHN health services, and improve health equity to the poorest of the poor in rural Honduras.

Uptake of UCOS Model Post-project • The MOH reports that the UCOS model needs more

testing and suggested several steps: (1) continue piloting and measuring results of the model; (2) reinforce the model with experiences from other rural service delivery projects in Honduras and other countries; and, (3) design a methodology and tools for the MOH to evaluate the model.

• ChildFund continues to support 16 of the 28 UCOS started during the project period, which fall within long-term ChildFund Honduras program service areas.

• 22 additional UCOS sites will be developed by ChildFund Honduras in an additional program area in the coming fiscal year.

Thank You!