Complementary Evaluation for EIP and Documentation of scale of Integrated Community Case Management in

Rwanda

- Key Findings -

Presented by: Laban Tsuma, MD, MPH PVO/NGO Support Advisor MCHIP, Washington DC

Presentation Outline

I. Background II. Objectives III. Methodology IV.Results V. Lessons Learned VI.Next Steps

2

Background

EIP CSHGP Program: •Focused on iCCM, CHW training, supervision and supply chain

•Encouraging peer support through modified care groups

Contributions to Scale: •Opportunity to learn about intervention(s) going to scale

•What was Rwanda’s planned versus actual pathway to scale for iCCM?

•How did EIP contribute to pathway?

Cross-District Comparisons: •Opportunity to compare quality of CCM delivered in EIP districts vs non-EIP districts

•Does the “modified care group” approach affect the quality of CCM? If so, how?

Objectives of Complementary Study

Scale Study:

To test the following Hypotheses

•NGO supported actions around HBM (2004) and iCCM (2007) were essential in leveraging MOH support for scale

•Strong leadership and political will in Rwanda were key in moving CCM to scale

Comparative Study:

To assess care group attribution to CCM status

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Methodology

The Complementary Study comprised of 2 different tasks.

Document Review + Qualitative elicitation of narratives by 17 key informants (central level stakeholders) to “tell the story” of iCCM in Rwanda over time (2001-2011)

Qualitative assessment of CCM status in one non-EIP district (Ruhango) targeting different groups

5

Interviews and FGDs Conducted Target Done

Central MOH & Central Partners (USAID, UNICEF, WHO, PNILP, NGOs)

5

Technical persons 1 MOH 11 NGO/Bilaterals

District Health Officer 1 Health professionals (Titulaire, CSC)

2

CHWs FGDs Mothers / Caretakers

FGDs

Cooperative Officials FGDs Focu

s G

roup

In

terv

iew

s

Results

A historical timeline for iCCM was elaborated. Also NGO contribution to some of these steps was mapped.

CHW Services are appreciated by both users and MOH.

Caregroups at the CHW level provide a natural peer support group and help with Community mobilization and BCC.

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CCM Timeline in Rwanda – Abridged Version

HBM Strategic Plan 2004

Expansion of HBM to 12 of 19

“endemic” Districts 2006

HBM Evaluations 2006 and 2007

using ACT

iCCM Pilot in Kirehe 2007

iCCM Tool Development and

revision 2008-2010 2009-Introduction

of RDT at community level

Expansion of iCCM to 30 Districts

2009-2010

1990’s 2003 2010 2006 2007 2008

PHC

DIARRHEA

MALARIA

PNEUMONIA

Home-based fluid and ORS and Zinc in Kirehe

First pneumonia case treated by a CHW in the country in Kirehe district Feb 2008

POLICY CH Policy + community health desk.

2005

RDT Policy Change

2009 2004

Pilot AQ at village level in 6 districts

Oct 07: Bukora HC, first ACT treatment by CHW

HBM Strategic Plan

C-PBF to incentivize CHWs

EXPANSION Expansion of iCCM to 30 Districts 2009-2010

CHW CCM Cadre mooted

HBM TWG

IMCI TWG

MCH CH TWG takes over from IMCI TWG.

Expansion of iCCM to 16 Districts 2008 (Phase 1)

HBM in 6 Districts

HBM in all 19 endemic Districts

Individual CSHGP Projects are awarded to 3 NGOs

Other Important Critical Events for CCM in Rwanda 1

Vision 2020 Umurenge of 2000 and Decentralization Policy of 2001

Global Fund Round 3 WHO TA and HBM Strategic Plan 2004 NGOs piloting HBM, CORE/PMI support

2004 CHW Recognition by the Presidency -

“Itorero” call; Cellphones 2008, IDHS 2008 10

Other Important Critical Events for CCM in Rwanda 2

Setting up of MOH Community Health Desk; BASICS TA for iCCM Pilot 2007

Rwanda MOH exchange visit to Senegal to examine CCM 2006; Re-districting in Rwanda

Global Fund Round 5 –DHS 2005; CBHI RCC and Global Fund Round 8; RDT

Introduction 2009; C-PBF roll-out C-PBF rollout; New staff cadre for CHW

Supervision nationally; DHS 2010

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Lessons Learned 1

The EIP played a significant role in the scaling up of iCCM in Rwanda by intervening at critical points in the pathway to scale.

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Lessons from Rwanda CCM evolution

HBM Scaling CCM has

been at 2 levels:- coverage or #districts, depth (+Pneumonia +Diarrhea +RDT +MUAC screening)

Clear MOH Policy and CH Desk

Strong Community confidence of CHWs and CCM program

Good funding levels via several partners including GF Rounds 3,5 RCC and 8, and PMI and USAID

Initial Planning always had scale in mind.

Rapid scale-up Unique Innovations

have been embraced like CBHI, c-PBF and SIScom

CCM Challenges that care groups could help alleviate

Key CCM Factors EIP Districts (with CHW Peer Support Groups aka Care Groups)

Non-EIP Districts (without CHW Peer Support Groups)

Improving Task Competency for CCM e.g. use of timer, use of MUAC, use of RDT

+

-

Improved Reading and Counseling on RDT result

+ -

Minimizing stock-outs by sharing inventory among peers

+ -

Technical Supervision by Peers + - Sharing Cases among CHWs to maintain CCM proficiency

+ -

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Lessons Learned 2

Immediate take home lessons for MCHIP following this study include consideration

-to support a validation study for CHW RDT application and reading;

- to co-opt peer support group formation and networking module in CHW training;

- for different CHW restocking models/ supervision models

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Lessons Learned 3

Immediate lessons to global stakeholders include

-Increased efficiencies in the evaluation process due to shared resources and expertise of different but complementary partners;

-Shared learning/Adopting lessons learned into ongoing programs/Sustainability

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Next Steps

Consider comparing DHS clusters from EIP and non-EIP areas from the recent DHS (2010)

Convene a face to face meeting for mutual agreement of CCM events timeline

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Thank you!

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