Post on 01-Jan-2017
Improving the Health and Nutrition Status of Women and Children
Promising Practices from East Africa
May 2013
Improving the Health baby september24-evening.indd 1 9/27/13 8:14 AM
Improving the Health and Nutrition Status of Women and Children
Acknowledgments
• HealthstaffatAlamataTownHealthCentreandDistrictHealthOffice
• WorldVisionEthiopiaMekeleProgramOffice
• Communityhealthworkers,hillleadersandhealthcentrestaff
• WorldVisionBurundinutritionandhealthstaff
• Healthworkers,communityhealthworkers,DistrictHealthManagementTeamandWorldVisionstaffat
BondoDistrict
WorldVisionisaninternationalpartnershipofChristianswhosemissionistofollowourLordandSaviourJesus
Christinworkingwiththepoorandoppressedtopromotehumantransformation,seekjusticeandbearwitnessto
thegoodnewsofthekingdomofGod.
Documentationteam:JoanMugenzi,WorldVisionEastAfricaRegionHealthandHIVMonitoringandEvaluation
Specialist,andDr.SisaySinamo,WorldVisionEastAfricaRegionNutritionAdvisor
©WorldVisionInternational2013
Allrightsreserved.Noportionofthispublicationmaybereproducedinanyform,exceptforbriefexcerptsin
reviews,withoutpriorpermissionofthepublisher.
PublishedbytheEastAfricaRegionHealthLearningCentreonbehalfofWorldVisionInternational.Forfurther
informationaboutthispublicationorWorldVisionInternationalpublications,orforadditionalcopiesofthis
publication,pleasecontactwvi_publishing@wvi.org.
SeniorEditor:HeatherElliott.ProductionManagement:KatieKlopman,DanielMason,DuncanMutavi.
Copyediting:AudreyDorsch.Proofreading:AmberHendrickson.Designandlayout:info@ablecreative.co.ke
Coverimage:JoanMugenzi/WorldVision
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Improving the Health and Nutrition Status of Women and Children
Contents
Executive summary.......................................................................................................................................................2
General introduction to the booklet.................................................................................................................3
1. Traditional Birth Attendants (TBAs): Embracing TBAs and cultural practices for
increased uptake of health facility services in Alamata District, Ethiopia......................5
1.1 Rationalefortheintervention.........................................................................................................................5
1.2 Interventionobjectives.......................................................................................................................................6
1.3 Keyactionstaken.................................................................................................................................................6
1.4 Achievements........................................................................................................................................................7
1.5 Successfactors,gaps,challenges.....................................................................................................................9
2. Focal Nutrition Learning Centres: Using locally available resources
to improve child nutrition in Burundi..................................................................................................... 11
2.1 Rationalefortheintervention........................................................................................................................ 11
2.2 Interventionobjectives.....................................................................................................................................11
2.3 Keyactionstaken............................................................................................................................................... 11
2.4 Achievements......................................................................................................................................................13
Casestudy1:WorldVisionfieldexperienceanditscontributiontothedevelopment
ofnationallevelFARNguidelines......................................................................................................................................16
2.5 Successfactors,gaps,challenges...................................................................................................................16
3. Defaulter tracing: Using defaulter tracing for essential maternal and child
health (MCH) services in Bondo District, Kenya.............................................................................19
3.1 Rationalefortheintervention........................................................................................................................19
3.2 Interventionobjectives.....................................................................................................................................19
3.3 Keyactionstaken...............................................................................................................................................20
3.4 Achievements......................................................................................................................................................23
Casestudy2:ANCandImmunisationsupportgroupsatGotMatarHealthCentre........................................25
3.5 Successfactors,gaps,challenges...................................................................................................................26
4. Community health worker functionality assessments: A means to strengthen
the health system in the region...................................................................................................................28
4.1 Rationalefortheintervention........................................................................................................................28
4.2 Interventionobjectives.....................................................................................................................................28
4.3 Keyactionstaken...............................................................................................................................................28
4.4 Achievements......................................................................................................................................................29
Casestudy3:KitgumDistrictinUgandabenefitsfromtheCHWsystemsstrengtheningapproach............30
4.5 Successfactors,gaps,challenges...................................................................................................................32
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Improving the Health and Nutrition Status of Women and Children
2
Executive summary
Since2012,theWorldVisionEastAfricaRegionHealthandNutritionteamhasembarkedonengagingwithnational
officestoidentify,documentandsharepromisingpracticesofainterventionsthathavehaddemonstratedimpactin
thecommunitieswhereWorldVisionworks.ThisisinlinewiththekeymandatesofLearningCentres.
ALearningCentre(LC)is‘agroupofpeoplewithrecognisedcapabilityinaspecificdiscipline,locatedinastrategic
nationaloffice,whodefinebestpracticesanddisseminateknowledgethroughouttheregionthroughface-to-faceand
virtualcollaboration,withafocusondrivingresults.’1
Theoverallobjectiveofknowledgemanagementpracticeistocapture,disseminate,andpromotetheuseofinternal
andexternallearningonhealthandnutritionprogrammes.WorldVisioncontinuestoseektheenhancementofthe
qualityandprofessionalismofitsprogramming,withthecapturingandexchangeofknowledgebeingkeytothiswork.
Inthisbooklettheteamsharesfourpromisingpracticesfromwhichnationalofficescanlearnandlessonswhichthey
canincorporateintohealthandnutritionprogramming.Thefourpracticesare:
• TraditionalBirthAttendants(TBAs):EmbracingTBAsandculturalpracticesforincreaseduptakeof
health-facilityservicesinAlamataDistrict,Ethiopia
• FocalNutritionLearningCentres:UsinglocallyavailableresourcestoimprovechildnutritioninBurundi
• Defaultertracing:Usingdefaultertracingforessentialmaternalandchildhealth(MCH)servicesinBondo
District,Kenya
• Communityhealthworkerfunctionalityassessments:Ameanstostrengthenthehealthsystemintheregion.
Thesepracticeshighlightsimpleinterventionsthathaveledtopositiveoutcomesinantenatalcareservices
uptake,skilledbirthattendance,nutrition,growthmonitoringandpromotion,immunisationuptake,and
benefitsaccruingfromacommitmenttohealthsystemsstrengthening.
Foreachofthepractices,thisbooklethighlightstherationalefortheintervention,interventionobjectives,keyactivities
takenandachievements.Italsonotessuccessfactors,gapsandchallenges,presentingagreatlearningopportunity.
Casestudiestoillustratebenefitsofsomeinterventionsarealsoincluded.
1 Africa LC High Level Operating Model V6(2010)(internaldocument).
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Improving the Health and Nutrition Status of Women and Children
WorldVisionInternationalhasprogrammesinninecountriesin
EastAfricathathaveacombinedpopulationofover247million.
Theregionhasunacceptablyhighinfantandunder-5mortalityrates,
at101and181per1,000livebirthsrespectively.Affordablehealth
interventions,whenmadeavailabletothemothersandchildren
whoneedthem,willpreventanestimated6.6millionchilddeaths
worldwideandtheMillenniumDevelopmentGoalnumber4,reduce
childmortality,couldbeachievedby2015.2
ChildmortalityinmostcountriesinEastAfricahasshowna
decliningtrendinpastdecades.However,bothneonataland
maternalmortalityhavelargelyremainedthesame.InEastAfrica,
neonatalmortalityaccountsfor22–31percentofunder-5deaths.
Sadly,progressinreducingdeathshasbeenslowerfornewbornsthanamongchildrenaged1monthto5years.3
Eachyearthousandsofwomendieinchildbirthorfromcomplicationsduringpregnancy.Ethiopia,Tanzania,Kenya,
UgandaandSudanareamongthe21countrieswiththemostmaternalandunder-5deathsin2008.
Chronicmalnutritionisadevelopmentalproblemandsilentemergencyinallcountriesintheregion.Thisis
worsenedbythehumanitarianemergency,whichthreatensthelivesofchildrenandtheaffectedpopulationinthe
region.ArecentDemographicandHealthSurvey(DHS)reportin2011showedthattheprevalenceofstuntingis
ashighas58percentinBurundi;underweightremainedacriticalpublichealthproblemintheregion(inEthiopia
underweightprevalencedeclinedfrom41percentto29percentbetween2000and20114);andwastingremained
highinchronicallyfood-insecureareassuchasSomalia,KenyaandsouthSudan(15percentto23percent).5
Accordingtothesamereport,anaemiaisthemajornutritionaldisorderamongchildrenandpregnantwomeninthe
region,resultinginadversepregnancyoutcomesaswellasunderweightbabies.
CountriesinEastAfricaRegionhavemadegoodprogressinthefightagainstHIVinfection.Inthepastdecade,the
prevalenceofHIVhasdroppedbymorethan40percentinanumberofcountries.Ugandahadmadegoodprogress
butnowseemstobelosingthebattle;around2007,theprevalencewas4.3percentbutthathasnowrisento
7.3percent,thehighestintheregion.Somaliahasthelowest,at1.4percent.6Inspiteoftheprogressmade,the
prevalenceisunacceptablyhighacrosstheninecountries.
2 GlobalHealthCouncil,A Global Health Council Position Paper on Child Health(2007).3 Countdownto2015,Countdown to 2015: Decade Report(2000–2010).4 EthiopianDemographicandHealthSurvey(2011).5 UNICEF,Progress on Child and Maternal Nutrition(2009).6Countryprogressreports2012(internaldocuments).
General introduction to the booklet
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Improving the Health and Nutrition Status of Women and Children
TheoverallgoaloftheEastAfricaregionalhealthnutritionandHIVandAIDSstrategyistocontributetothe
improvementofthehealthandnutritionalstatusofwomenandchildreninWVoperationalareas,workingin
partnershiptodevelopthecapacitiesofnationaloffices(NOs)todesign,implementandmonitorhighimpactand
cost-effectivehealth,nutritionandHIVandAIDSprogrammes.
Since2012,theEastAfricaRegionhealthandnutritionteamhasbeguntoengagewithNOstoidentify,document
andsharepromisingpracticesofinterventionsthathavemadeadifference.Fourpracticesarepresentedinthis
booklet.SomeofthesepracticeshavefullybeenpublishedbytherespectiveNOs(e.g.Burundi);dissemination
eventsforthesepracticeshavebeenheld(EthiopiaandRwanda);andlearninghasbeengleanedfromwhatother
partnersaredoing(defaultertracingforessentialservicesinBondoDistrict,Kenya).
Theregionhasdecidedtoworkstrategicallythroughthecommunityhealthsystem,andsinceNovember2011,
hassupportedNOstoconductcommunityhealthworker(CHW)assessmentsasawayofcontributingtowards
healthsystemsstrengthening(HSS).HSSisahealthandnutritionstrategicapproachfocusingonequippingCHWs
tofacilitateimplementationofcorehealthandnutritioninterventions.Inthisbookletweshareourexperience
conductingtheassessments,andweprovideacasestudyfromUgandashowingprogressfollowinginvestmentsin
communityhealthstructures.
Wehopethisbookletwillbebeneficialtoyou.Manythankstoourteammembers,JoanMugenziandSisaySinamo,
fortakingtheleadonthisexercise,andtothevariousnationalofficeteamsthatcontributedtothecompilationof
thisbooklet.
MesfinLoha
Director,HealthandHIVandAIDS
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Improving the Health and Nutrition Status of Women and Children
1.1Rationalefortheintervention
AlamataTownDistricthealthcentreisoneof47districtfacilitiesthatfallundertheMekelleRegionalHealthBureau
inthenorthernpartofEthiopia.ItislocatedintheSouthernTigrayZone.Amongtheeightdistrictsinthiszone,
AlamataTownDistrict,whichservesapopulationof37,600people,emergedastheworstinstitutionaldelivery
healthserviceproviderforfourconsecutiveyears(2005–2008).Thehealth-facilitydeliveriesinthisareawere
appalling,astheregionalhealthbureaunoted.
TheAlamataTownDistricthealthofficenotedthelowratingbuttooknoactiontoimprovethesituation.Itwas
cleartherewasgoodantenatalcare(ANC)duringthefirstandsecondtrimestersofpregnancybutlowinstitutional
delivery.
PartofAlamata’sexplanationforpoorperformancewasthepossibilityofpoorcounselling.Theythoughtof
preparingpostersoninstitutionaldeliverybutdidnotactonthat.
ThisscenarioledtheheadoftheMekelleRegionalHealthOfficetocommentthattheAlamatafacilitywasbetter
off‘keepingcattle,’observingthattherewasnoservice.TheAlamataTownDistricthealthofficereceivedthis
commentinthemidstofalackofequipmentanddeliverytools.
Theregionalfeedback,alongwithathreattoclosethefacilityifthepoorperformancecontinued,becameawake-
upcallfortheAlamataTownDistricthealthservicestotakeactiononthegaptheywerealreadyawareof.Although
therewasanongoingplanandachievementreviewandreflection,thelowperformanceremainedduetolackof
readinessamongthehealthworkerstochangethesituation.Laterthehealthworkersstartedtoidentifysolutions,
oneofwhichwaslinkingwiththecommunityhealthworkersandnursehealthextensionworkers(HEWs),which
helpedthehealthworkerstoplanandachievebetterperformance.
Amongthekeyactionswasastudyoninstitutionaldeliveryinthecommunity.Thestudy,carriedoutinJune2010,
found53childrenwithoutimmunisationand169pregnantwomenwithoutANCfollow-up.Discussionswereheld
withthemothers,andhealthworkersidentifiedpertinentissuesthatcalledforattention.
Keyissuesraisedbymothersweretheperceptionsthat:
• onlywomenwithproblemsdeliverathealthfacilities
• therewasashortageofstaffatthehealthfacilities
• thedeliveryenvironmentwasunhygienic,carryingtheriskofHIVduetocontamination.
Healthpersonnelalsoidentifiedpositiveculturalpracticesandbeliefsthatkeptwomenpreferringtodeliverat
home.Suchpracticesincludedthecoffeeceremonyattheonsetoflabour,preparatorymaterialssuchasutilities
formakingporridge,celebrationofthebirth,andthespiritualrelevanceofcallingonMotherMaryatthetimeof
delivery.
Besidesthesepracticesandbeliefs,theservicechargeandtheabsenceofdeliveryservicesatthehealthcentre
duringoff-dutyhours(5p.m.–8a.m.)wereotherhindrancestosomemothers.
Althoughthehealthworkersbelieveditwasnotpossibletochangethesituation,onesupervisorproposedtheidea
ofbringingpregnantwomenandtraditionalbirthattendantstogethertochangethesituation.Theresponsefrom
someofthecolleagueswas,‘Isitpossible?’Withhesitationtheideawasmovedforward,andlaterothercolleagues
startedtosupportitandadistrictgoalwassettoseemothersdeliveringinthehealthfacilities.
1 Traditional Birth Attendants (TBAs): Embracing TBAs and cultural practices for increased uptake of health-facility services in Alamata District, Ethiopia
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1.2Interventionobjectives
• Toreducehomedeliveriesto0percentintheshortesttimepossible
• Toensurethatnomotherdiesfromlabouranddelivery,accordingtotheMillenniumDevelopmentGoal
(MDG)
1.3Keyactionstaken
Toachievethedesiredobjectives,thedistrictundertookvariousactions,includingthefollowing:
• Conductedasurveytoidentifypregnantwomeninthetown.Theyfoundatotalof169pregnantwomen(of
whom93hadTetanusToxoid1and4hadTetanusToxoid2).Inaddition,theyidentified53childrenwithout
age-appropriateimmunisationcoverage.Thestudyalsohelpedthedistricthealthservicestoestablishmothers’
understandingofthebenefitsofinstitutionaldeliveryandissuesrelatedtoit.
• ApproachedWVforsupport,whichenabledthemtoacquireskillsthroughtrainingoftraditionalbirth
attendantsandawareness-raisingamongthemothersontheimportanceofinstitutionaldeliveriesandthe
supportivesupervisiononsite.
• Providedtrainingtopregnantwomenatthehealthcentre.Itincludeddiscussionsonthebenefitsofinstitutional
deliveryandrisksofhomedelivery,suchasHIV,bleeding,etc.Thetrainingalsoincorporatedanunderstanding
ofthehealthcentreenvironment,includingshowingthecleanlinessofthedeliveryroomandproviding
testimonialsfrompregnantwomenlivingwithHIV.Allthewomenwhoattendedthetrainingreceivedtetanus
toxoid(TT)immunisationandlong-lastinginsecticide-treatednet.In2010noneofthewomen’sspouses
participatedinthetraining,soin2011spousesweredeliberatelytargetedtobepartofthetraining.This
trainingalsocreatedabetterunderstandingoftheproblemsathand,andmotherswerealsoabletounderstand
theservicesoffered,therisksofhomedeliveryandthebenefitsofinstitutionaldelivery.
• Trained27traditionalbirthattendants(TBAs)and1,165HealthDevelopmentArmy(HDA)workers:this
assistedthehealthofficetointegratetheTBAsintheHDA.AnHDAisagroupofvolunteersselectedfromthe
communitytopromotehealthservicesforfivehouseholdsinthecommunity.Notethatthe27TBAstrained
werepartoftheAlamataTownDistricthealthservicespriortothefacilitytakingdeliberatestepstoimprove
institutionaldeliveryservices.Afterthetraining,TBAsagreedtocounselandaccompanypregnantwomen
tothehealthfacilitiesfordelivery.OneofthekeysuccessstoriesofthisprocesswashavingtheleadTBA,
famousforhomedeliveries,referpregnantwomentothehealthfacilities.TheTBAswereattachedtoHEWs
forsupervisionpurposes.ThetelephonenumbersoftheHEWsandtheambulanceweregiventotheTBAsfor
easycontact.
• Discussedservicedeliveryimprovementsatthefacilitylevel.
• Increasedthehealthcentreandhospitalfocusoncleanliness,referralforuseoftheambulanceavailableat
thehospital,trainingofhealthstaff(onemidwifeandonenurse),provisionoffreehealthservicedeliveryto
pregnantwomenandlactatingmothers,introductionofemergencyobstetriccareatthehospitalandinitiation
ofdeliveryservicesatthehealthcentre.ThroughWVandothersources,theyacquiredcriticalmaterialssuch
asadeliverycouchandMCHdrugs.
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Improving the Health and Nutrition Status of Women and Children
• Withdrewtheserviceofprovidingandrefillingdeliverykits(gloves,soap,GentianViolet,Tetracycline,
eyeointment,cotton,etc.)totraditionalbirthattendantstopromoteinstitutionaldelivery.Thedistrict
healthofficeworkedincollaborationwiththeReliefSocietyofTigraytoprovideincentivesforTBAsinthe
community.
• Institutionalisedculturalpracticesthatdonotaffectthehealthofthemotherorthedeliveryoutcome,suchas
thecoffeeceremony,celebratingthebirthofthechildandplacingapictureofSaintMaryinthewaitingandthe
deliveryrooms.
• Workedonwaysthehealthworkerswouldhandlemotherswhentheycomefordelivery.Thisledtobetter
practicesandbehavioursamongthehealthworkers,suchascourtesy,creatingabetterdeliveryenvironment
andimprovingthelinkagewithHEWsandtheHDA.
• Documentedallthepregnantwomenineachofthekebeles(villages);thesearecontinuallyfollowedupto
thepointofdelivery.Thisearlyidentification,registration,referralandfollow-upofmothersmadeagreat
contributiontouptakeofservices.
• Trackedandmonitoredtheperformanceofkebele-levelHEWs.
• Sensitisedthetraditionalandkebeleleadersontheneedforinstitutionaldeliveryandtheleadershipsupport
theycouldprovide.
• ImplementedtheHDApolicy,whichtheEthiopiangovernmentintroducedaroundthetimeofimproving
institutionaldeliverieswithinthedistrict.TheWomenDevelopmentArmies(WDAs)arecommunity-selected
volunteersandmodelmotherswhohaveabetterunderstandingandpracticeofthehealthextensionpackages.
Thehealthextensionpackagecomprises16interventionstargetingthehousehold(HH)level.TheycoverMCH
(includingnutrition),hygiene,sanitation,andinfectiousandcommunicablediseases.EachWDAleaderhas
responsibilityforfivehouseholds.Theyknowwhichmothersarepregnantandtheyreferthepregnantwomen
totheextensionworkers.Currentlyhealthworkerscontinueongoingassessmentofpregnantwomenand
lactatingmothers.Mothersreceivepreventionofmother-to-childtransmissionofHIV(PMTCT)services,and
afterdeliverytheyarereferredforimmunisationservices.CommunityHEWsalsoregisterallpregnantwomen,
documenttheexpecteddeliverydateandfollowupathome(atleast90percent).
Thedistricttappedintothisopportunitytointegratethe27previouslyactiveTBAsintotheHDAstructure.Rather
thansupportthemtoconductdeliveries,thedistrictfocusedontrainingthemonkeymaternalissuesandturned
themintomobilisersforhealth-facilityserviceusage–discussingthebenefitsofinstitutionaldeliveriesandrisksof
homedeliveries.
1.4Achievements
AlamataTownDistricthealthservicesregisteredvariousachievementsthatresultedinthedistrictprogressingfrom
theworst-performingdistrictintheSouthernTigrayZonetothebest-performingdistrict.Belowarehighlightsof
achievementsandtrends.
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Improving the Health and Nutrition Status of Women and Children
Antenatalcareandinstitutionaldelivery
• FollowingthetrainingofmothersandTBAsandthesensitisationofthecommunitygroups,asustained
increasewasobservedinthenumberofmotherscomingtothehealthfacilitiesfordelivery.Emphasison
institutionaldeliveryalsoledtoanincreaseintheuptakeofANCafteroneyearofintervention;there
wasaslightdropinyeartwoandanincreaseinyearthree.(SeeFigure1.)
Figure 1: Trend of ANC and institutional delivery in Alamata Town District (2008-2011)
ANC
Institutionaldelivery
2008
1,400
1,200
1,000
800
600
400
200
0
2009 2010 2011
Year
Nu
mb
er
• Accordingtokey-informantinterviewswithhealth-facilitypersonnel,itisestimatedthathomedeliveries
havedeclinedfrom50percentto7percent.Dataforhomedeliveriescannotbegeneratedfromthehealth
managementinformationsystem(HMIS)becauseTBAactivitieswerescrappedfromtheHMIS.Health-
facilitydatashowedtherewasaclearimprovementinuptakeofANCandinstitutionaldeliveryservices,with
anincreaseof72.5percentinANCservicesand246.9percentincreaseindeliveries.Figure2showsthe
performanceinAlamatatownpriortotheinterventionin2008andagainin2011,whentheanalysisofthepost
interventionwasdone.
Figure 2: Baseline and post-intervention in Alamata Town
2008
2011
ANC
743
1,400
1,200
1,000
800
600
400
200
0
687
Delivery
Year
198
Nu
mb
er
1,282
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Improving the Health and Nutrition Status of Women and Children
Preventionofmother-to-childtransmissionofHIV
• ThenumberofwomenwhoknowtheirHIVstatushasincreased.AllwomenwhoattendANCaretestedfor
HIV,andthosewhoarefoundpositiveareregisteredforPMTCTandlinkedtooneofthefiveHIV-positive
mother-supportgroups.BasedontheJuly2011annualDistrictHealthOfficereport,860womenwereenrolled
forPMTCTservices,comparedwithonly38womenin2008.Thishighlevelofenrolmentcanbeattributedto
thedeliberateidentificationandfollow-upofpregnantwomenforhealth-facilityservices.
MothersandfamilyinvolvementtosupportMCHusage
• Mothersindicatedthattheyareadvisingothermotherstodeliverinhealthfacilities.Theyalsoreportedthat
theydiscussedthebenefitsofMCHserviceswiththeirpartnersandaskedfortheirtosupportinusingthe
services.Mothersarehappyfortheirownandhealthworkers’roleinpreventingillnessessuchasHIVand
ensuringdeliveryofhealthychildren.
• Regardinginclusionofmeninfamilyinvolvement,TBAsreportedthatduringtheWVtrainingwomenwere
alsoencouragedtoeducatetheirpartnersonANCandinstitutionaldelivery.TheHDAalsoencouragesmen
totakecareofwomenduringhomevisits.ParticipationduringPMTCTandsupportbeginsatthetimeofthe
marriage.(Theyshouldtestbeforetheygetmarried.)CurrentlythecommunityisalsocarryingoutHIVtesting
beforemarriage.
1.5 Successfactors,gaps,challenges
Successfactors
• ThecloseinterestoftheMekelleRegionalHealthBureauinwhatwashappeningwiththehealthservicesin
Alamata
• TheAlamataTownDistricthealthservicesteam’scommitmenttoaddressingtheproblemofpoorperformance
• Thedecisiontoconductastudytoclearlyunderstandanddefinetheproblemofhomedeliveries
• Theadoption/integrationofculturalpracticesandbeliefsvaluedinhomedeliveries,suchasthecoffee
ceremonyandcelebrationofthebirth
• TheavailabilityofpartnerssuchasIntraHealth,OrganizationofSocialServicesforAIDSandWorldVisionto
supportvariouscomponentsoftheintervention
• WinningoverthechiefTBA
• Understandingtherisksandbenefitsofhomeandhealth-centredelivery
• UsingHIV,analreadyfeltproblem,asanentrypointofemphasisforinstitutionaldeliveries
• IntroductionoftheWomenDevelopmentArmy,withoneofitsrolesbeingtoensureclosefollow-upand
counsellingofmothers
• Districtprovisionthatifawomandiesasaresultofahomedelivery,theTBAandhusbandareheldresponsible
forthatmaternaldeath
• Useofcriticalcommunitystructuressuchaselders,Kebeleleadersandfaith-basedorganisationstoemphasise
themessageofthebenefitsofinstitutionaldeliveries
• ContinuedtrainingofTBAs,mothersandspouses,andleadersonthebenefitsofinstitutionaldeliveriesandthe
risksassociatedwithhomedeliveries
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Improving the Health and Nutrition Status of Women and Children
Gaps
• Shortageoffinancesfortraining,henceheavyrelianceonpartnerssuchasWorldVision.
• Lackofemphasisonthebirthpreparednessplan.Forinstance,mothershavetocallfortheambulanceatthe
onsetoflabour.
• Shortageofdeliveryequipment(e.g.vacuums,Ambubag,deliverysets,Autoclave).
Challenges
• Culturalbeliefs(suchasfearofdeathandfearofannoyingthespiritsinthehome,whichcanresultindeath),
systemsandpractices.Someofthesebeliefshavehadanimpactontheappreciationofimmunisationand
family-planningservices.
• LimitedmaleinvolvementinPMTCTservices.
• UnwillingnessofsomeTBAstostophome-deliveryservicesinthecommunitybecausetheyfearalossof
dignityandtheyfeeltheyareaddressinganeed.‘IwillnotstophelpingmothersdeliverathomebecauseI
haveacalltohumanityforthemotherswhostillwanttodeliverathome,’saidoneTBAinaFocusGroup
Discussion(FGD).
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Improving the Health and Nutrition Status of Women and Children
2.1Rationalefortheintervention
Burundiisfacedwithaburdenofchronicmalnutrition.Accordingtothe2010DHSreport,threeoutoffivechildren
under5(58percent)sufferfromstunting;almosthalfofthese(27percent)sufferseverechronicmalnutrition,
while6percentarewasted.TheStateoftheWorld’sChildrenreport2009(UNICEF),statesthat39percentof
childrenunder5areunderweight(moderateandseveremalnutrition,2000–2007).Anaemiaprevalenceinchildren
aged6monthsto59monthsisalsohigh,standingat45percentaccordingtothe2010DHSreport.Poorfeeding
practices,poorhygieneandahighprevalenceofcommunicablediseasescontributetothehighlevelofmalnutrition
withinBurundicommunities.
A2010Knowledge,AttitudeandPracticestudybyUNICEFshowsthatcomplementaryfeedingaftersixmonthsis
insufficientinbothqualityandquantity.Thesamestudyshowedonly32.9percentofchildrenunder2receivethree
mealsaday.Thequalityanddiversityofmealsisnotadequate.Only27.8percentofchildrenfromruralareasaged
6monthsto11monthsreceiveamealcontainingthethreefoodgroups.Thefoodispoorinprotein.Thechildren
eatmainlygrains,tubersandotherroots(45.5percent)andfruitsandvegetables(27.7percent),whilethenumber
whoreceivemeat,eggsormilkproductsislow(7percentformeat,8.8percentforeggsand6percentformilk
products).
AreviewofthesurveyfindingsintheWorldVisionoperationareashowedhighlevelsofchronicmalnutritionamong
childrenunder5(Table1).
Table 1: Malnutrition levels in Burundi area development programmes (ADPs)
ADP Stunting Underweight Wasting Year survey (GAM) conducted
Bugenyuzi 53.0% 37.9% 6.2% July 2009
Gashoho 55.3% 32.4% 4.8% Oct 2010
Gasowre 57.8% 35.4% 5.6% Nov 2010
Gitaba 54.0% 34.9% 7.4% June 2012
Ntunda 63.7% 31.0% 5.7% July 2012
2.2Interventionobjectives
• Rehabilitatemalnourishedchildren
• Topreventnewcasesofmalnourishment
• Tosustainbestpracticesusinglocallyavailablefoodstuffs
2.3Keyactionstaken
Tofulfiltheobjectives,WorldVisionBurundiintroducedtheFoyer d’Apprentissage et de Rehabilation Nutritionelle–
FARN(NutritionEducationandRehabilitationCenters).FARNisalocallearningcentrewheremotherslearnabout
complementaryfeedingpracticesinordertoimprovethewell-beingofchildrenaffectedbymalnutrition.7
2 Focal Nutrition Learning Centres: Using locally available resources to improve child nutrition in Burundi
7 Focal Nutrition Learning Centers: Using Locally Available Resources to Improve Child Nutrition.FieldExperienceinBurundi (August2012)(internaldocument).
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Improving the Health and Nutrition Status of Women and Children
Thisapproach,endorsedbyBurundi’sMinistryofHealth(MoH),isbeingimplementedinWorldVisionADPs.FARN
usessimilarprinciplestoPositiveDevianceHearth(PD/Hearth)anditspurposeistorehabilitatemalnourished
childrenunder5byusinglocallyavailablefoodproducts,mobilisingthecommunityandinducingbehaviourchange
usingthebehaviourchangecommunicationapproach.
AboutPD/Hearth
PD/Hearthisaninternationallyprovencommunity-basedmodelforrehabilitatingmalnourishedchildrenintheir
ownhomes.Ittargetsmoderatelyandseverelyunderweightchildrenagedbetween6monthsand36months.
WorldVisionfollowedallthestepsforitsFARNimplementation.Communitymobilisationstartedwithengagement
ofthelocalleadersandidentificationofvolunteers.Thecommunitysetitsowncriteriatoselectvolunteers:can
readandwrite;haswell-nourishedchildren;hasacleanhouse,havingatoiletandwithanimalslivinginaseparate
building;isamodelinthecommunity;andcancommittimetofacilitatetheFARNsessionsandworkforthe
communityforfree.Bothsexeswereequallyrepresented.Themainactivitiesofthevolunteerswereasfollows:
• Sensitisethecommunityandconductscreening.
• Maintaintheregisterswithchild’sname,mother’sname,father’sname,child’sage,child’sweightandheightat
admissionandafter12daysand30days,attendanceatFARNsessionsanddate.
• Analysethedataandcapturerecordsofallthechildrenidentifiedasmoderatelymalnourishedfor
rehabilitationinFARN,orreferchildrenwithseveremalnutrition.
• SuggestrecommendedfoodtypesandothercontributionforFARNsessions.
• Followupmothersintheirhomesafterthe12daysofFARNsessions.Thisensuresthatmotherscontinue
practisingthebehaviourstheylearnduringtheFARNsessions,suchasdiversifyingthefoodandwashingtheir
handsbeforepreparingthefoodandfeeding.Thefactthattheyarenothavingreadmissionsisanindicatorthat
themothersarepractisingwhattheylearn.
• IdentifyandpreparethelocationforPD/Hearthsessions.ThehomewheretheHearthwasestablishedhadto
belongtoaPositiveDeviantfamily–afamilywithawell-nourishedchild.Italsoneededtobehygienic,spacious
andeasilyaccessiblebymostmembersofthecommunity.
• Mobilisethemotherstocontributewater,firewoodandfoodsuchassweetpotatoes,cassava,bananas,beans
andvegetables.Insomesessionsmotherscontributed100Burundifrancseach,whichwasusedtobuycooking
oil,smallfishandgroundnuts.WorldVisionprovidedcookingutensils,matsandthetarpaulinforshade.
• Throughhill8leadership,sensitisethecommunitiesonGrowthMonitoringPromotion(GMP)andremind
motherstotaketheirchildrenforGMPactivities.
Foreachhill,positivedevianceinquiry(PDI)wasconductedonce.Sincethereisonlyonehill-levelleadershipand
volunteergroupconductingthesessionateachhill,therewasonlyoneFARNsessionconductedinonehousehold.
Duringthetrainingoffacilitators,afoodcompositiontablewasusedtocalculatethenutritionalrequirements,
whichwerethenconvertedtothelocalunits.However,fillingtheironrequirementfromlocallyavailablefoods
duringthemenu-planningmeetingwasnotpossible.Table2showsachild’ssamplemenupreparedduringtraining.
Itwasnotpossibleforallvolunteerstoconductvisitseveryonetotwodays.Theydid,however,managetoconduct
weeklyvisits,dependingontheneed.
8AhillisalocaladministrativeunitatthevillagelevelinBurundi.
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Improving the Health and Nutrition Status of Women and Children
13
Table 2: Sample menu prepared during a Hearth session
Food/meal Weight in grams Home measurement
1. Lengalenga 80 gms Handful
2. Cassava (pate) 25 gms 2 Tablespoonful
3. Haricot beans 50 gms Handful
4. Oil 10 gms 2 Tablespoonful
5. Salt 2 gms 2 Pinches
6. Groundnut 50 gms Handful
Snack
Banana 48 gms 1 small piece
2.4Achievements
Sessionsheldandvolunteersmobilised
Twohundredandfivesessionsweresuccessfullyconductedin48hills(seeTable3).Atotalof510volunteerswere
trainedtofacilitatetheFARNsessions.
Table 3: Number of health sessions conducted and volunteers trained, by ADP
ADP Hills # of sessions Children # of children admitted rehabilitated
Rugazi
Gashoho
Gasorwe
Cankuzo
Rutegama
Mushikamo
Total
12
6
11
8
5
6
48
3
2 (one session per hill)
205
24 (2 sessions per hill)
26
7
19
16
12
32
35
7
6
301
82
155
236
22
26
2,431
177
104
308
434
75
78
219
67
131
162
16
19
2,157
152
82
218
549
69
54
433 419
16 (two sessions per hill)
2010 2011 2012 2010 2011 2012 2010 2011 2012
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Improving the Health and Nutrition Status of Women and Children
ChildrencoveredinFARNsessions
Out of the 10,568 children screened, 2,052 childrenwere found to be underweight andmalnourished andwere
admittedtoWVFARNsessions inFY2011and2012.TheaveragenumberofchildrenperFARNsessionwas11.
Amongtheparticipants,59percentwerefemaleand41percentmalechildrenunder5(Figure3).
Figure 3:TotalnumberofchildreninWVFARNprogramin2011and2012(N=2,028)
1,188(59%)
840(41%)
male
female
ThemajorityofchildrenwhoparticipatedintheHearthsessionswereaged12monthsto23months,followedby
thoseaged24monthsto35months.Nearlyhalf(43.5percent)ofthetotalnumberofchildrenwhoparticipatedinthe
FARNsessionswereundertheageof24months(Figure4).Thisprovidesahugewindowofopportunitytoprevent
theimpactofchronicmalnutritionanditsirreversibleconsequences.
Figure 4: Age distribution of children admitted to FARN 2011 & 2012 (n=2,052)
24–35 months
36–48 months
49–60 months
>60 months
700
600
500
400
300
200
100
0
12–23 months
6–11 months
0-11
mon
ths
12-2
3 mon
ths
24-3
6 mon
ths
36-4
8 mon
ths
49-6
0 mon
ths
>60 m
onth
s
250
643
503
326
252
78
Nu
mb
er
Age
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Improving the Health and Nutrition Status of Women and Children
Rehabilitationoutcome
Recovery rate at 12 days and 30 days of FARN sessions:Among2,052childrenintheprogramme,
2,022completedthe12-daysessions.Ofthose,1,526(76percent)gainedtheweightneededfortransfertothe
homevisit,witha1percentdefaulterrate(Figure5).Duringthe2011implementationperiod,manyoftheFARN
sessionsdidnotmeasuretheweightofchildrenat30days.Thisisbecausethevolunteerswerenottrainedtotrack
theweightofchildrenoncetheyweredischargedfromtheprogramme.However,in2012thevolunteersweighed
atotalof807childrenandcomparedtheirweightwiththeiradmissionweight.Overall,631(78percent)ofthe
childrenhadgainedover400gatonemonth,meetingtheprogrammegraduationcriteria.At30days,theproportion
ofchildrendefaultingfromtheprogrammehadincreasedto14percent(Figures5and6).
Figure 5:FARNoutcomeindicatorsat12days(N=2,022) Figure 6:FARNoutcomeat30days(N=807)
Death
Defaulter
No weight change
Weight loss
Weight gain 0-200g
Weight gain over 200g
Death
Defaulter
No weight change
Weight loss
Weight gain 0-200g
Weight gain over 200g
Theoutcomeoftheintegratedhealthserviceswasthatchildrenreceivedbenefitssuchasdeworming,vitaminAand
thelinkagetohealthservices.TheADPmanageratGashohostatedthatchildrenintheirADPwereenjoyinggood
health.Thelocalgovernmentalsoextendeditsrequesttoexpandtheservice.
Average weight gain:Bytheendofthe12days,theaverageweightgainoftheprogrammewas373g.Bytheend
ofthe30daystheaverageweightgainwas689g.ThedistributionoftheweightgainissummarisedinFigure7below.
Figure 7: Distribution of weight gain by the of 30 days (n=677)
250
200
150
100
50
0
Number of children
100 - 300 400 - 500 600 - 700 800 - 900 1kg & over
Weight in gms
47
237
180
86
127
Nu
mb
er
of
chil
dre
n
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Improving the Health and Nutrition Status of Women and Children
ImpactofFARNonoverallmalnutritioninthecommunity
GrowthanalysisusingtheWorldHealthOrganization(WHO)standard:UsingStandardizedMonitoringand
AssessmentforReliefTransition(SMART)software,workersconductedanalysistoassessthelevelofmalnutrition
atadmission,at12daysandafter30daysofinvolvementintheFARNprogramme.Improvementsinchildgrowth
areshowninTable4.Theresultwasthatthelevelofsevereunderweighthasdeclinedfrom49.2percentto
17.2percent(WAZscore<−3SD,seeTable4).Thereislittlechangeinmoderatemalnutrition,whichcouldbethe
resultofmovementofmanyofthechildrenfromseveremalnutrition.
Table 4: Levels of malnutrition after FARN sessions (N=677)
No Malnutrition
At Risk of malnutrition (WAZ < 0 & > -1 SD)
Mild Malnutrition (WAZ < -1 & > -2 SD)
Moderate malnutrition (WAZ < -2 & > -3 SD)
Severe Malnutrition (WAZ < -3 SD)
Admission 0.0% 4.9% 16.2% 29.8% 49.2%
12 days 1.5% 6.7% 20.2% 31.9% 39.7%
30 days 2.3% 17.4% 37.0% 26.1% 17.2%
Case study 1: World Vision field experience and its contribution to the development of national level FARN guidelines
TheFARNapproachisamongthecommunity-basednutritioncomponentsofthenationalprotocolof
managementofacutemalnutritionwhichwasvalidatedinApril2010.Aftertheprotocolvalidation,the
nutritiondepartmentofthegovernmentofBurundianditspartnersembarkedonaprocesstodevelop
FARNnationalguidelines.WVBurundiwasamongthepartnersthatcontributedtothedevelopment
oftheseguidelines.AmeetingofvariouspartnerswasheldintheMoHin2011topresenttheFARN
approachestheywereusing.WorldVisionparticipatedinthismeetingandsharedtheRugaziFARN
experience.InAugust2011,attherequestofMoH,WorldVisionsharedtheguidelinesitisusingtorollout
FARNinitsoperationareas.Afive-dayworkshopwasorganisedinGitegaProvinceinDecember2011to
designthefirstdraftofFARNguidelinesforBurundi.
WVBurundi’sHealth,NutritionandHIVprogrammeofficerwasonthesix-membercommitteetasked
tofinalisethedraftguidelines.TheothercommitteememberswerefromInternationalMedicalCorps,
WorldFoodProgramme(WFP),UNICEFandthegovernment.BasedontherecommendationoftheGitega
workshop,thecommitteeconductedafieldvisittoFARNsites,includingWorldVision’s,andreviewedthe
implementationfeasibilityanddrewlessonsbeforefinalisingtheFARNguidelines.
WorldVisionwasinvitedtoparticipateinthefinalisationandadoptionoftheFARNnationalguidelines
workshopheldonApril26and27,2012,inGitegaProvince.Duringthismeeting,theWorldVision
NutritionistspecialistAristideMadagashamadeapresentationontheWorldVisionimplementation
strategy.ThedecisiontorequestWorldVisiontomakeapresentationfollowedajointUNICEF-WFPfield
visittoRutegama,RugaziandGasorweADPs,April24and25,2012.
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Followingthismeeting,atechnicalcommitteewassetuptofinalisetheFARNnationalguidelinesdocument.
Again,WorldVisionwasselectedtobeapartofthiscommittee,whichalsohadrepresentativesfrom
UNICEF,WFPandtheMinistryofHealthnutritiondepartment.WorldVision’smajorinputwasrequired
forimplementationmodalities,especiallybudgetingforFARNsessionactivities,specifyingkeyinputsthat
needtobeplanned.
Duringthefirstweekofthenationalforumfornutritionandfoodsecurity(December2011)WFPand
UNICEFaskedWorldVisiontomakeapresentationonPD/Hearthandtheimplementationprocess.It
wasthefirsttimethegovernmentorganisedaforumtodiscussnutritionandfoodsecurityissueswithall
thepartnersinvolvedinnutritionandfoodsecurityactivities.Theforumalsoattractedparticipationfrom
regionalleadersofUNagencies.
2.5Successfactors,gaps,challenges
Successfactors
• CommunityparticipationandactiveinvolvementisthebackboneoftheFARNprogramme–akeysuccess
factor.Communityinvolvementcanincludeprovidingleadership,sensitisation,identificationandsupporttothe
volunteers,identifyinghouseholdstohosttheFARNsessionsandcontributingthefoodandequipmentneeded
fortheFARNsessions.ThehealthpromotiontechnicianforKaruzidescribesthecommunityashighlywillingto
participateandcontributetotheFARNsessions.
• TheexperienceatGashohoADPillustratesthecommunitycontribution.TheFARNsessionsareorganised
withvolunteersselectedfromthecommunitywiththeleadershipofthehillleaders.Thegrouphasaboutequal
representationofmenandwomen.Thishashelpedtoinvolvemeninthepromotionoftheprogramme.
Currently115trainedvolunteercommunityworkersareactivelyinvolved,witharetentionrateof95.8per
cent.WorldVisionprovidesaraincoatandatransportallowancewhenthevolunteerstravelfortraining,but
thereisnootherincentive.
• Inoneofthecommunitymeetingsavolunteersaid,‘Weareworkingforourownchildreninthecommunity
andthechildrenofBurundi.Weworktoprotectthemfromillnesses;wearehappywiththeworkandwill
continueworkinguntiltherearenomalnourishedchildreninthecommunity.Therelationshipwiththefamilyis
goodandthatismotivationforus.’
• Initiallymenthoughtthatifthemotherstookfoodfromtheirhomestothesessions,thenthechildrenathome
wouldnothaveenoughtoeat.Fathersalsodidnotunderstandhowmotherscouldspend12daysattheHearth
sessions.Volunteersandcommunityleadershelddiscussionswiththemenandrealisedthatoneofthemajor
concernswasthetimethemothersspentattheHearthsessions.Theyagreedtospendamaximumoftwo
hoursatanyHearthsession.
• BeforestartingPD/Hearth,WorldVisionenteredaMemorandumofUnderstandingwiththeMoHto
implementFARNinthecommunity.Astheimplementationstarted,WorldVisionfieldteamsmetwiththe
districtandprovincialofficestodiscusstheimplementationprocess.Table5describeshowpartnerswere
involvedduringtheFARNimplementation.
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Table 5:RoleofPartners’inFARNimplementation
Partners Roleofpartners
HC/healthpromotiontechnicians • Followupactivitiesandmonitoringofrehabilitatedchildren.• Trainingvolunteers.• Conductscreeningandgrowthmonitoring,de-wormingandvitaminA
supplementation.• Examinationofchildrenwithmalnutritionandtreatthem,selectcases
andtreatforillnessesandrefercaseswithmedicalcomplicationtostabilisationcentre.
• Training,sensitisationofmothersandsupervisionofcommunityhealthworkersandvolunteers’activitiesinthecommunity.
TheDistrictandProvinces • Supervisionandextensionplanstootherareasbuttheseareatearlyphase.
• Ownershipoftheapproachandsupport.
CommunityandHillleaders • Sensitisationandcommunitymobilisation.• Supporttothevolunteerstoeffectivelyprovidetheirservices.• Contributefood,referchildrenforscreening.
WorldVision • FacilitateMoUwithpartnersandallocatethefund.• Transportfeeduringtraining,conductjointsupervisionandreview
meeting.• Assignfocalperson.• ImplementintegratedprojectsthatsupportFARNactivities.• Shareditsexperienceandprovidedafield-basedlearningtoinformthe
nationalFARNguidelinedevelopment(refertothecasestudy1).
Challenges
Duringakey-informantinterviewAlexisKabona,aPathfinderemployeewhoworksonhealthandnutrition
programmesinthedistrict,identifiedthefollowingchallengestoFARNimplementation:over-population,limited
landsizeandlowfamily-planningpractice.
Othermajorchallengesemergedfromkey-informantinterviewsandfocusgroupdiscussionswithWorldVision
staff,healthworkers,provincialanddistrictofficials,volunteers,andthebeneficiaries.Theyaresummarisedas
follows:
• lackofgrowthmonitoringandpromotioninthecommunity
• lackofinstitutionalisationoftheFARNactivitiesaspartoftheoutreachactivities;onlychildren
whocometothecurativeservicesarecurrentlygettinggrowthmonitoring
• limitedfield-levelstaffandlackoftransportationtoconducton-sitesupportandensurequalityof
theFARNsessionsanddatamanagement
• foodshortageinsomeseasonsandlackoforpoorqualityofoil
• mothersbringingsimilartypesoffood
• reluctanceofsomecommunitymembers,forreligiousreasons,toallowweighingofchildren
• highpopulationpressure
• women’slackofdecision-makingpoweronresources.
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3.1Rationalefortheintervention
Bondoisoneof37districtsofNyanzaProvinceinKenya,withatotalareaof1,084km2,ofwhich500km2isLake
Victoria,thesecondlargestfreshwaterlakeintheworld.ItbordersBusiaDistricttothewest,SiayaDistricttothe
north,SubaDistricttothesouthandRariedaDistricttotheeast.Therearesixinhabitedislandsand66beaches.
BondoDistricthasoneofthehighestinfantmortalityratesinKenya,at110infantsper1,000livebirths,whilethe
under-5mortalityrateis208per1,000livebirths.Maternalmortalitystandsat620per100,000livebirths,well
abovethenationalfigureof488per100,000recordedbytheKenyaDemographicandHealthSurvey2008–2009.
Thedistricthas34healthfacilities,comprising1hospital,7healthcentresand26dispensaries.Thegovernment
ownsthehospital,6healthcentresand18dispensaries;theothersareownedbyprivatesector/faithbased
organisations.
ForthreeorfourconsecutiveyearstheindicatorsforessentialMCHserviceswerenotgood,withskilledbirth
attendancestandingat17percent,fullimmunisationinthe50s,fourthANCvisitandfamilyplanning(FP)low.The
AnnualOperatingPlan6(AoP)indicatorsbecameadecisivepointinMay2011.Immunisationcoveragewasbelow
60percent,thoughthenationaltargetis80percent;FPuptakewasaround46percent;andANCvisitswerealso
low(BondoMoH).Therewerecasesofdropoutforservices,meaningthatthosewhoinitiallyreportedforservices
didnotreturn.Therewasnounderstandingofwhyclientsweredroppingout.Itwasequallyconfusingthat,withthe
highnumbersofCHWs,thedistrictcouldnotmeetitstargets.Thisobservationindicatedaneedforanevidence
basefordecision-making.Thedistrictimplementedthecommunityhealthstrategyin2010toensurecommunityuse
ofthehealthfacilities.However,realignmentofcommunityunitstonewpolicystartedinMarch2011.
Themissionofcommunityhealthservicesisforthecommunitytobecomethemeansofsocialtransformationfor
developmentatthecommunitylevelbyestablishingequitable,effectiveandefficientcommunityhealthservicesin
communityunitsalloverKenya.
ThekeyfocusforBondoDistrictwastorevamptheCHWstructureandestablishafocusondefaultertracing
forimmunisationandANC.Theydidthisbyintroducinganexitdeskatallhealthcentres,staffedbyCHWsona
rotationalbasis;theyalsointroducedanappointmentsdiaryinwhichtheycouldtrackcontinuingusersofhealth
servicesandmapthedefaulters.
ThedistrictdeterminedtochangeitsseeminglygloomyscenariowithAoP7(2011/2012).‘Wethoughtwecould
accelerateCUcoverage,’saidJoelMilambo,communityhealthstrategyfocalperson,chargedwithensuringthe
rolloutofthenewcommunityhealthstrategy.TheDistrictHealthManagementTeam(DHMT)wantedasystem
thatwouldbeabletoaccountfordefaulters,especiallypregnantwomenandchildrenagedunder1year,besides
accountingforotherhealthservices.
3.2Interventionobjectives
StrengtheningofdefaultertracingforessentialMCHservicesbyintroducinganexitdeskandanappointmentsdiary
inallhealthfacilitieswasguidedbythreeobjectives:
3 Defaulter tracing: Using defaulter tracing for essential maternal and child health (MCH) services in Bondo District, Kenya
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Improving the Health and Nutrition Status of Women and Children
• toimprovecommunityandfacilitylinkage
• toestablishanevidencebasetoinformMCHplanninginthehealthfacilities
• toimproveuptakeofANCandimmunisationservicesformothersandchildrenunder1year.
3.3Keyactionstaken
Thedistricttookthefollowingactionsasawayofstrengtheningthecommunityhealthservicesstrategy:
• revampedtheoldCHWstructure,whichhadoneCHWcovering20HHs,andfollowedthenewpolicy
guidelines(2010)thatprovideforoneCHWper100HHs;thisnewstructureinformedtherecruitmentof
CHWs
• recruitedCHWsandCHCmembersasperthenewpolicyguidelines
• trainedtheCHWs
• conductedhouseholdmappingandregistration,whichisnowdoneeverysixmonths
• institutedperformance-basedassessmentforCHWs,identifyingspecifictargetstomeet
• hiredanadditional10communityhealthextensionworkers(CHEWs)tosupervisetheCHWstructure
• engagedkeystakeholders,includingprovincialadministratorssuchaschief,villageheads,assistantchief
• disseminatedtherevisedMoHreportingtools
• strengthenedcommunitydialoguedays(discussinghealthissueswiththecommunity,informedbythe
indicatorsonthechalkboard)andactiondays(executinganactionplanagreedonduringthedialoguedays)on
amonthlybasis
• introducedtheexitdeskstaffedbyCHWsonrotationalbasis
• introducedanappointmentsdiaryasawayoftrackingdefaultersattheexitdesk.
Engagingcommunityhealthworkers
Recruitment
FromMarchtoMay2011thedistrictplacedadvertisementsinvarioussublocations,callingforCHWs.Thevillage
headsthenidentifiedCHWstoinvolveintheprocess.Theseweresenttothechief’sbaraza(communitymeeting),
wheretheywerevettedandrecruited,followinggovernmentguidelines.RecruitmenttookplacebetweenMayand
July2011.
Training
Afterrecruitment,CHWsreceivedorientationandtrainingonthecommunityhealthservicesstrategyintheir
respectivesublocations.ThelastmajorCHWtrainingthatfocusedoncommunitystrategywasconductedin
October2011.Duetolimitedresources,thistrainingranfor10daysinsteadofthestipulatedsixweeks.The10-day
trainingcoveredcommunitycasemanagement;communityHMIS;TB/HIV;diseasepreventionandcontrol;water,
sanitationandhygiene(WASH);andcommunitymaternalandnewbornhealth.Itisimportanttonotethatall363
CHWshavereceivedtraining.
Job aids
Followingtraining,CHWsreceivedvarioustoolstodotheirwork,includingthehouseholdregister(MoH513),the
CHWservicedeliverylogbook(MoH514),whichisfilledinonamonthlybasistogeneratedata,andachalkboard
forthehealthfacilities.Thechalkboardprovidesaglimpseofthehealthstatusofanygivenfacility.CHWsalso
receivedthestandardMoHcommunityreferralforms.
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Improving the Health and Nutrition Status of Women and Children
Besidesthetools,CHWsreceivedotherjobaidssuchasbadges,bagsandInformation,Educationand
Communication(IEC)materialsspecificallyfocusingonMCH.
Household mapping and registration
Followingthetraining,thefirstCHWactivitywashouseholdmappingandregistration.Dependingonthenumberof
householdsaCHWhadtocover,theexercisetookfromfivedays(forthosewithlessthan100HHs)totwoweeks
(forCHWswithmorethan200HHs).ThemappingwasdonewithakeyfocusofestablishinganumberofMCH-
relatedindicators,includingthenumberofpregnantwomen,numberofchildrenunder1year,numberofchildren
exclusivelybreastfed,numberofwomenofreproductiveage.
Target setting
Afterthemappingexercise,CHWssettargetstoachieveonamonthlybasis.Theideabehindthisexercisewasto
ensurethatastheCHWsdidtheirwork,theyhadatruepictureoftheircatchmentareasandwouldknowwhat
particularhouseholdstoprioritiseforvisits.
Continuing training
TheCHWsreceivedcontinuoustrainingfromvariouspartners.Someofthetrainingprovidedwasonmother-child
integratedprogramming,reportingtoolsandinfectionpreventionandcontrol.
Staffing the exit desk
Oneveryworkingday(MondaytoFriday),anassignedCHWwillbeatthehealthfacilityfrom8a.m.to4p.m.and
willgeneratealistofpatientswhoareexpectedtocomeforservicesandthosewhohavedefaulted.Thisprocessis
facilitatedthroughanappointmentsdiary.
The appointments diary
Theappointmentsdiaryisacriticaltooldesignedtotrackcontinuingserviceusers.Theserviceusersareidentified
fromtheANCandimmunisationregisters.Itwasnoted,however,fromthevisitedsitesthatuseofthistoolisnot
standardised.TheentriesvarywiththeCHWs.Inonecase,forexample,diaryentriesreflectedacompiledlistof
defaultersattheendoftheday;othershadsimplymarkedparticipants,providingnosummaries,andrecordsfor
somemonthsweremissing.Inanotherdiary,bothnewandcontinuingclientswereregistered.
Astheappointmentsdiarywasdistributedtothehealthfacilities,nospecifictrainingonitsusewasprovided.This
lefttheCHWswithoutadequatesupportforusingthetool.
Remuneration
Communityhealthworkersarevolunteers.BondoDistrict,however,isfortunatetohaveapartnerMaternaland
ChildHealthIntegratedProgrammewhohascommittedtoprovideastipendof2,000Kenyanshillings(Kshs–
approximatelyUS$25)tothe363CHWsinthearea.ThisstipendisbasedontheamountstipulatedinKenya’s
March2011communitystrategypolicyguidelines.However,thestipendisnotguaranteed.Aworkermustscoreat
leastfiveoutofsevenpointsinamonthinordertoreceivethismoney.Theareasassessedforperformanceare:
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Improving the Health and Nutrition Status of Women and Children
• referralofatleasttwopregnantwomen
• referralofachildforimmunisation
• participationindialogueandactiondays
• householdvisits
• completeandtimelysubmissionofreports
• communitymobilisation
• defaultertracing.
Figure 8: Defaultertracingflowchart
Extract list ofdefaulters from
the diary
Make phonecalls to CHWs
concerned
CHW visit thehome of a defaulter
CHWs defineswho is a defaulter
CHW soughtreason for defaulting
defaultercentered reason
YES
Refer to healthfacility for
service
Seek assistancefrom fellowCHW/CHC/
CHEW/HF/PA
Follow up toconfirm referral
Health facilityvisit to checkreferral file
Home visit to check health
card
NO
CHW negotiates
with defaulter
Otherreasons
Message directed to the party
concern
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Improving the Health and Nutrition Status of Women and Children
3.4Achievements
StrengtheningthedefaultertracingforessentialMCHserviceswiththeintroductionofanappointmentsdiarywas
thekeyactivityinBondoDistrict,guidedbythreeobjectives.Thissectionspellsouttheachievementsthedistrict
hasregisteredfromJune2011toJuly2012.
Theappointmentsdiary
Theappointmentsdiarytofacilitatedefaultertracingwassuccessfullyintroducedinallthethreedivisions,enabling
BondoDistricttotracktargetsandgeneratedatathatinformtheirplanning.Oneoftheindicatorsofinterestfor
managementisthenumberofpregnantwomenwhodonotattendatleastfourANCvisitsasshowninFigure9.The
DHMTindicatedthattrackingsuchinformationenablesthemtosystematicallyplanforimprovementastheyare
nowabletogenerateanevidencebase.
Figure 9: ANC non-attendance in Bondo District
700
600
500
400
300
200
100
0
JUL-
13
AU
G
SEPT
OC
T
NO
V
DEC JAN
FEB
MA
RC
H
APR
IL
MAY
JUN
-13
Pregnant women who did not attend at least4 ANC Visits
No.
of m
othe
rs
Months
Defaultertracing
Althoughitwasnotpossibletoestablishalldefaultersidentifiedacrossthedifferentservices,therewererecords
forimmunisation(recordingbothdefaultersthatwereidentifiedandthosewhoweretracedandsubsequentlytook
upservices).Anotherproxyindicatorfordefaultertracingwasthenumberofpregnantwomanreferred,asshown
inFigures10,11and12.
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Improving the Health and Nutrition Status of Women and Children
Figure 10:ImmunisationdefaultersidentifiedinBondoDistrictFigure 11: Immunisation defaulters traced
900800700600500400300200100
0
No
. of
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-12
1,200
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Immunisationdefaulters
Figure 12: Pregnant women referred to the health facilities in Bondo District
sre
hto
m fo .
oN Pregnant women
referred
Months
700
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-12
Strengtheninghealthstructures
Thedistrictestablished26communityunits(100percent)coverage,recruited52CHEWsandidentified260
communitymembers.
TherewasnotableimprovementinthelevelofcommitmentofCHWs.Respondentsrevealedthatwiththeold
policy,inwhichoneCHWwasassigned20HHs,CHWsweretoomany,andtherewasnodemonstrableimpactof
theirwork.
Increaseinuptakeofmaternalchildhealthservices
TherewasanincreaseinuptakeofMCHservices.AttendanceatthefourthANCappointmentincreasedby
17percent(from4,995clientsinAoP6[2010/11]to5,868clientsinAoP7[2011/12]),skilledbirthattendanceby
28percent(2,444mothersinAoP6comparedwith2850inAoP7),familyplanningby6percent(20,335clients
inAoP6comparedwith21,478inAoP7)andPMTCTby9percent(1,122mothersinAoP6comparedwith1,226
mothersinAoP7).(SeeFigure13.)UptakeofimmunisationservicesforBacillus Calmette–Guérin (BCG)increasedby
67percent(5,484childrenreceivedtheBCGantigeninAoP7comparedto3,277thepreviousyear).
(Seefigure14.)
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Improving the Health and Nutrition Status of Women and Children
Figure 13: Uptake of key maternal health services in Bondo District
25,000
20,000
15,000
10,000
5,000
0
SBA PMTCT
AoP6
AoP7FAMILY
PLANNINGANTENATALCARE
Maternal health services received
No.
of w
omen
Figure 14: Uptake of immunisation services in Bondo District
Immunisation antigens received
No.
of c
hild
ren
6,000
4,000
2,000
0
AoP6
AoP7
BCG MEASLES FULLYIMMUNISED
ORAL POLIOVACCINE
Case study 2: ANC and Immunisation support groupsat Got Matar Health Centre
TheprocessofdefaultertracingforessentialMCHservicesledtosomeotherinnovations.GotMatarHealthCentre,acentrethatwaselevatedfromadispensarylevelatthebeginningofthisyear,introducedANC-and-immunisationsupportgroups.
Accordingtothenurseinchargeofthisfacility,thisefforthasseenmoremotherscompletethefourANCvisitsandallmothersinthegroupdeliveringatthefacility.Theotherbenefitisthatmothersinthegroupshavebeenabletodoexclusivebreastfeeding.Thegroupsrunontheirown.Thefacilitybecomesinvolvedonlytoprovidetechnicalsupportwhenmothersaregrapplingwithpracticalquestions.Mothersmeetonamonthlybasis,andtheyhaveintroduced‘Merry-go-rounds’,whereeachmothercontributesKshs30.Themoneyispooledandgiventoonemother.Mothersareencouragedtousethismoneyfortheirbirthplans.Thefacilityalsoensuresthatmothers’ANCvisitsarescheduledonthesamedayastheirsupportgroupmeetings.
Thefacilityhasnotgonewithoutchallenges:‘Thedispensarywasgazettedasahealthcentre,butintermsofstaffingwehaveremainedwhereweare,’saidthenurseincharge.‘Theworkloadistoomuch.Wearemulti-taskingtomanage.’
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Improving the Health and Nutrition Status of Women and Children
3.5Successfactors,gaps,challenges
Successfactors
• Commitmentofapartnertoprovidetheperformance-basedmonetaryincentive.ThegovernmentofKenya
stipulatesamonthlystipendforCHWsofKshs2,000(approximatelyUS$25).
• IntegrationoftheCHWsintothemainstreamhealth-facilityserviceprovision,whichwonthemmorerespect
fromthecommunities
Gaps
• Alotisbeingdoneontheground,butthereisnosystematicwayofcapturingthedefaultertracingactivities
thathavereportedlybeenspreadacrossallthe26communityunits.The363CHWsaredoingalotofwork
thatmaygounrecognisedduetolackofevidence.
• Therehasnotbeenanydetailedtrainingondefaultertracingforallcadresofhealthworkers.Thismayaffect
thequalityofservice.
Challenges
• Somereligiouspractices(e.g.thoseofNomiyachurchandtheRohomovement,whichkeepchildrenindoors
forthreemonthsbefore‘exposingthem’tothesurroundingenvironment)resultsinmembersofsuchsects
defaultingfromkeyservices.
• Themigrationpatternoftheboarderpopulationaffectstheoutcomeoftheservices.Itiseasytolosefollow-
upaspopulationsarenotinonespace.
• Sustainabilityoftheprogrammebeyondacommittedpartnerisquestionable.
• Thequalityofthedataisachallenge.Anumberofindicatorsarenotconsistentlyrecorded,whichmightlead
tounder-orover-reportingofresults.
• WhilstthetargetforCHWsisform-fourcompletion,thestipend,whichisamajormotivation,isnotattractive
enoughtothetargetrecruits.InaninterviewwithaCHEW,herevealedthatmostoftherecruitsarebelow
formfour.Peoplebelowthislevelfinditverydifficulttoconceptualisetheissues.TheCHEWshavetospend
moretimeaddressinggaps.
Service-specific challenges
• LongwaitingtimefortheANCprofile,insomecasesuptosevenhours,especiallyforthefirstvisit.This
mayaffectsubsequentvisits.Partoftheexplanationforthisisthatgovernmentpolicyguidelinesprovidefor
detailedengagementwithamotheronthefirstvisit.OneDHMTmembersaidtheyneedtotreatclientsasif
theywillnotseethemagain.
• FearoftakingtheHIVtest.
• Painofthevaccinationshot.
• PerceptionthatHCsaresimplymakingprofitofftheuserfees.
• Perceptionthatmalehealthworkerswillmakesexualadvancestothewomen.
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Improving the Health and Nutrition Status of Women and Children
Timeandcostinganalysis
Time
ThemajorityofCHWswhoparticipatedintheFGDsindicatedthatittakesanaverageofone-and-a-halftotwo
hourstoconvinceadefaultertogobacktothehealthfacilityforservices.Somecasescantakeuptotwodays.This
isdependentonaclient’srelationshipwiththeCHW,client’sperceptionofqualityofservicesatthehealthfacility,
thelevelofsupportfromthespouse,conflictinginterests(e.g.whethertoattendtootherpressingneeds)and
distancetobecovered.Itispossiblethatsuchextrahoursspentdoingprogrammeworkmayfailtobecaptured
whenplanningCHWsstaffhoursandinturnbecomeasourceofdemotivation.
Costing analysis
Itwasnotpossibletoascertaintheactualcostofwhatittakestorunadefaultertraining.However,thefollowing
elementsareofsignificantimportance:
Training:Thisisakeycomponentandamajorexpenditureareaofadefaultertracingprogramme.Itisimperative
thatalltrainingcostinputsbecapturedtopaintaclearpictureofwhatittakestoinitiateandmaintainadefaulter
tracingprogramme.DemandforadditionaltrainingsessionswasexpressedbyCHWsinmosttheFGDs.
Reporting tools and job aids:Anothermajorareaofconsumableexpenditureworthcostingisthe
communityhealthinformationsystem,whichincludesdevelopment,productionanddistributionofthefollowing
reportingtools:householdregister(MoH513),servicedeliverynotebook(MoH514),CHEWssummaryreport
(MoH515),CHWstandardisedreferralform,motherandchildhealthbooklet(MoH216),childcliniccard,
immunisationregister(MoH510),ANCregister(MoH45)andchalkboard(MoH516).Currentlytheseareprocured
inNairobianddistributedtothefield.OccasionalshortageswerereportedbytheDistrictMedicalOfficerof
Health(DMOH);insuchcases,theformsarephotocopiedlocally.Alongwiththesearejobaids/toolssuchasIEC
materials,bags,T-shirtsandbadgeswhichareissuedtoCHWstofacilitatetheirwork.
Airtime: CHWuseofthehealthfacility’smobilephonetotracedefaulterswasreported.Thishasacost
implicationinthepurchaseofairtimetomakecalls.
CHWcallstoescortclientstothehospitalwerereportedinoneFGD.Itisimportanttocapturethesegestures
astheyhaveabearingonthepressureofworkontheCHWandtheCHWmayalsobespendinghisorherown
moneytotransportthedefaulter.
CHEWs’ direct support to the CHWs:Thisisanotherareathatrequirescostingtomonetisetheinputs.
Theseincludesupportivesupervision,updates,on-jobtrainingandfeedbacksessions.
Transport facilitation for CHWs e.g. bicycles: CHWsreceivebicyclestofacilitatetheirhomevisitsas
wellasmotivatethem.However,manyoftheCHWshavenotyetreceivedbicycles.
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Improving the Health and Nutrition Status of Women and Children
4.1Rationalefortheintervention
TheUSAIDHealthCareImprovement(HCI)projectdevelopedtheCommunityHealthWorkerAssessmentand
ImprovementMatrix(CHWAIM)toolkittohelporganisationsassessCHWprogrammefunctionalityandimprove
programmeperformance.Builtaroundacoreof15componentsdeemedessentialforeffectiveprogrammes,
CHWAIMincludesaguidedself-assessmentandperformance-improvementprocesstohelporganisationsidentify
programmestrengthsandaddressgaps.Throughdiscussionandreviewofcurrentpractices,theprocessassists
understandingofbestpractices,buildsconsensusaboutandcommitmenttochangeandprovidesguidancefor
improvingfunctionality.
CHWAIMassiststheassessment,improvementandplanningofCHWprogrammesbydeepeningunderstanding
oftheelementsofsuccessfulprogrammesandtheuseofbestpracticesasanevidence-basedapproachto
improvement.Theassessmentisbasedonalignmentwithnationalguidelines.
WorldVisionInternationalmadeadecisiontousetheCHWAIMin2011.InEastAfrica,healthsystems
strengtheningisoneofthehealthandnutritionstrategicapproachesfocusingonequippingCHWstofacilitate
implementationofcorehealthandnutritioninterventions.Thetoolwasthereforeembracedtoachievethefocus
onHSS.
4.2Interventionobjectives
TheCHWAIMtoolhasclearlyspeltoutobjectivesforanyfunctionalityassessment.Theseobjectivesprovidethe
basisforstrengtheningacommunityhealthsystem.Thethreeobjectivesare:
• toassessfunctionalityandguideimprovementinprogrammesdeliveringservicesatthecommunitylevel
• toprovideactionplanningandbestpracticestoassistinstrengtheningprogrammes
• tomapfunctionalCHWprogrammesandgapsincoverage.
4.3Keyactionstaken
• ReviewofcountryCHWpolicy.
• AdaptationofthevalidationtoolaspertheCHWpolicy.
• Athree-daystakeholdersworkshopforthescoringoftheprogrammaticcomponents.Thisactivity
includesreviewingthetoolandprovidingaclearexplanationofwhatisentailed.
• Avalidationexercise–interviewingCHWstovalidatetheinformationprovidedinthestakeholdersworkshop
• Areviewofthescoresnormallyprovidedintheinitialmeetingwithstakeholders.
• Developmentofanimprovementmatrixclearlyspellingoutwhatactionsneedtobedone,andwhodoeswhat
Variousstakeholdersusuallytakeupdifferentaspectsforimprovement.
Processofrollingoutthefunctionalityassessments
Opportunitiestoadaptthetoolcamewithgrantopportunitiesthatwereintendedtoworkthroughtheexisting
communityhealthstructures,specificallytheEastAfricaMaternal,NewbornandChildHealth(EAMNeCH);Access
toInfantandMaternalHealth(AIM-Health);SustainableTransformationinAgricultureandNutrition(SUSTAIN)in
Tanzania;andActforLifesavingActionstoReachMothers(ALARM)inBurundi.
4 Community health worker (CHW) functionality assesments: A means to strengthen the health system in the region
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Improving the Health and Nutrition Status of Women and Children
TheEastAfricahealthandnutritionteamhasworkedwithNOstosupportengagementwithministriesof
healthtoprofiletheimportanceofCHWfunctionalityassessmentasakeyprocessincommunityhealthsystems
strengthening.Accordingly,representativesfromfiveNOhealthteamsandMoHdelegatesweresupportedto
attendthecommunityhealthworkerprogrammesustainabilityandscalabilitymeetingorganisedbyUSAID-HCIin
June2012.
CHWAIMproposes15programmaticcomponentsthathavebeenfoundtocontributetoaneffectiveCHW
programmebasedoninternationalbestpractices.Thesearerecruitment,CHWrole,initialtraining,continuing
training,equipmentandsupplies,supervision,individualperformanceevaluation,incentives,communityinvolvement,
referralsystem,opportunityforadvancement,documentationandinformationmanagement,linkagestohealth
systems,programmeperformanceevaluationandcountryownership.
Foreachofthe15components,fourlevelsoffunctionalityaredescribed:non-functional(level0),partiallyfunctional
(1),functional(2),andhighlyfunctionalasdefinedbysuggestedbestpractices(level3).
4.4Achievements
TheinitialassessmentsweredoneinNovember2011,andthesecontinuedthroughoutcalendaryear2012.Sofar15
assessmentshavebeenconducted,and27areplannedforFY13.(SeeTable6.)
Table 6: CHW functionality assessment status, December 2012
National office Funded by
Districts covered
Total # of districts in which WV is operational
Number of health facilities covered
Assessments planned for FY13
Number of assessments done
Burundi
Kenya
Rwanda
Tanzania
Uganda
Total
2
5
1
2
5
15
ALARM – AusAid
AIM – Irish Aid
EANMNeCH
Sponsorship
EANMNeCH-
AusAid
AIM
EANMNeCH
SUSTAIN-Canada
ADP budget
AIM
EANMNeCH
CHN campaign
2
1
1
3
1
2
1
8
6
25
8
55
13
21
30
127
2
11
9
0
1
4
27
19
15
22
11
15
133
68
283
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Improving the Health and Nutrition Status of Women and Children
TheseassessmentshavestrengthenedWorldVision’scollaborationwiththeWHO.InUganda,forexample,World
VisionworkedcloselywithWHOinconductingtheCHWfunctionalityassessmentalongsideahealthservices
availabilitymapping(SAM)intwodistricts.AlthoughWHOhadbeenconductingSAMsinUganda,theteam
mentionedtheyhadneverdoneanassessmentatthefirstlevelofserviceprovision.
InRwanda,WorldVisioniscloselyworkingwithWHOandtheMoHfortheassessmentsplannedforFY13.
Throughtheassessmentsconductedsofar,CHWprogrammefunctionalitywasfoundtoeitherbenon-functionalor
partiallyfunctional,afindingthatrevealstheneedtopayattentiontothisfirstlevelofserviceprovision,giventhat
WViscommunitybased.
Aconsistenttrendinfindings(14outof15assessments)isthatofhighestscoresinrecruitmentandinitialtraining,
withlowestscoresinequipmentandsupplies,supervision,incentivesandreferralsystem.
Forthevariousassessmentsdone,animprovementactionplanwasdevelopedasameanstofollowupprioritised
areasforsystemsstrengthening.KitgumDistrict,whereaspecialprojectwassolicited,isagoodexampleofwhat
happensoncethefunctionalityassessmentisdoneandanimprovementmatrixisdeveloped.
Case Study 3: Kitgum District in Uganda benefits from the CHW systems strengthening approach
TheEAMNeCHfive-yearprojectwasstartedinJuly2011withthepurposeofimprovingmaternal,newborn
andchildhealth(MNCH)inselectedcommunitiesfourEastAfricancountries:Kenya(KilifiDistrict),Rwanda
(GicumbiDistrict),Tanzania(KilindiDistrict)andUganda(KitgumDistrict).
Theprojectareaswerechosenbecauseofpoorhealthoutcomes,particularlyrelatedtoMNCHand
specificallyMDGs4and5.Theyhadweakhealthsystems,characterisedbyinadequategovernmentcapacity
torecruit,trainandretainmotivatedhealthpersonnelatboththecommunityandfacilitylevels.Health
informationsystemswereweak,withalackofinformationflowingfromcommunitiestotheMinistryof
Healthandviceversa.Despitemanyhouseholdsgrowingfoodforthemselves,nutritionknowledgearound
storageandusagewasinadequate.Accesstoappropriatesanitationservicesandhygieneknowledgewasalso
limited.PoliciesrelatingtoMNCHservicesexisted;however,theirimplementationinthefourprojectareas
wasweak.
ThemajorapproachfortheUS$9millionprojectisensuringincreasedaccesstoservicesthroughimproved
healthsystemstrengtheningandeducationatboththecommunityandfacilitylevel.
ThroughtheKitgumClusterInUganda,WorldVisionispartneringwiththeKitgumDistrictLocal
GovernmenttoimplementtheEAMNeCHprojecttocontributetotheimprovementofmaternalnewborn
andchildhealthinLagoroandMucwinisub-countiesby2016.TheprojectsupportstheDistrictHealthTeam
(DHT)inanendeavourtoimproveequitableaccesstoanddemandforMNCHservices
ByGeoffreyBabughirana,EAMNeCHprojectmanager,andAnitaKomukama,researchanddocumentationofficer
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Improving the Health and Nutrition Status of Women and Children
OneoftheavenuesthroughwhichaccesstoanddemandforMNCHserviceshasbeensolidifiedisthrough
thesupportoftheMinistryofHealth’scommunityhealthcaresystemofVillageHealthTeams(VHT).This
entailssupportingthelinkagebetweenthehouseholdsinthecommunityandthehealthsystemforincreased
accesstoMNCH.TheVHTmembersareempoweredtoeducateandpromotehealth-carepractices,
hygieneandsanitation;promotionofmaternalandchildhealth;conductactivecasefinding;appropriate
timelyreferraltothenearesthealthunit;andmobilisingforhealthservicesattheintegratedoutreachposts.
However,fortheVHTstobeabletocontributepositivelytotheaboveoutcomes,thedistrictneededto
knowthestatusoftheirfunctionality,usingtheMinistryofHealth2010VHTstrategyasthebenchmark.
UsingtheCHWAIMtool,theoverallassessmentrevealedthattheCHWprogrammeisatapartially
functionalstage.Supervision,individualperformanceevaluation,opportunityforadvancement,and
documentationandinformationmanagementwerefoundtobeincriticalneedofimprovement.
Whereastherewereseemingly321VHTmembers,255(79percent)didnotqualifytobeVHTsasthey
hadnotundertakenthefive-daybasictrainingasstipulatedintheUgandaVHTpolicy.Ofthe321whowere
doingVHT-relatedwork,47percentreportedhavingthebasictoolsandequipmenttoservethe7,617
householdsin120villages.
InterventionWiththefindingsfromtheassessment,theEAMNeCHprojectembarkedonadistrict-ledprocessto
implementasystematicVHTcapacity-buildingplan.Sincethen255VHTmembershavebeentrainedand
equippedwiththebasictoolkit(register,counsellingcards,participants’manualforreference,andreferral
form).VHTsdoqualityvillagewalksandtheyupdatetheirregistersonamonthlybasis.EachoftheVHT
membersisinchargeofatleast30households.
Tostrengthenthelinkagebetweenthehealthcentreandthecommunity,theprojectissupportingand
facilitatingVHTmonthlyreviewandstatusupdatemeetings.Onaverage,157VHTmembersinteractwith
thehealthcentrestaff.ThesemeetingsremindVHTsoftheirmonthlyschedules,includingmobilisationfor
outreaches,WASHimplementation,upcomingmassimmunisationcampaigns,qualityVHTvillagewalks,
updatingregisters,reportingandsubmissionofreports.
Aspartofthesupportofferedtothehealthcentrestocontributetothegovernment’sPrimaryHealth
Carestrategy,theprojecthasundertakentosupporttheVHTsastheyconductmobilisationandmonthly
outreachsessions.Atotalof30staticoutreachpostsarebeingsupportedeverymonthtoconductGMP,
ANCandprenatalcare(PNC)services.TwoVHTmembersonarotationalscheduleatthehealthcentres
supportthehealthworkersinthisregard.VHTsmobilisefortheseoutreacheswhenevertheytakeplace.
Achievements• Inaperiodof18monthsfollowingtheintervention,theoverallratinghasimprovedfrom42per
centto68percent.Thedistrictgenerallystillhasachallengewithtwocomponents:opportunityfor
advancement,andincentivesandremuneration.Theprojectispartoftheworkoftheteamthatis
facilitatingaVHTproductivitystudyconductedbyMoH;theplanisthatthiswillguidethesystemon
howtoprovideperformance-basedsustainablepayfortheVHTs.
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Improving the Health and Nutrition Status of Women and Children
• DatafromtheHMISfromJunetoDecember2012presentsevidencethat,duetotheintensification
ofintegratedoutreaches,230ofthe781FirstANCattendancesreceivedtheservicesthroughthe
outreaches,givinga29.4percentcontribution;ofthe434fourthANCattendances,146received
theservicesthroughtheoutreachservices,givinga33.6percentcontribution.Thisappliestoallthe
otherindicatorsintheHMIS.
• FromtherecentlyconcludedLotQualityAssuranceSamplingsurveyconductedandcomparingto
thebaselinesurvey,itwasestablishedthatVHTsupportofpregnantwomenhadincreasedfrom30.8
percentto42percent;coverageforcounsellingonferroussulphateandfolicacid(FEFA)forthelast
pregnancyincreasedfrom34.5percentto48percent;and17.5percentto61.1percentcoverageon
healtheducation(thatincludesdangersignsinpregnancyusingajobaid)forthelastpregnancy.Itis
alsoimportanttonotethatattendanceatoutreachGMPsessions,includingweighingandchartingthe
childhealthcard,increasedfromzeroto74percent.\
• DuetotheeffortsoftheVHTsindoingcommunitymobilisationforintegratedoutreaches,
cumulativelyforthereportingperiod(June2012–December,2012)4,817childrenhavebeenoffered
GMPservicesand791womenofferedANCservices,ofwhom376havetakenFEFAattheoutreach,
212havetakentheHIVtesttocontributetotheeliminationofmother-to-childtransmissionofHIV
(eMTCT),and415weregivenintermittentpresumptivetreatmentasapresumptivetreatmentfor
malariaduringpregnancy.Becausetheprojectisgendersensitive,40couplesweretestedforHIV;264
wereofferedPNCservices;264tookafamily-planningservice;and55menreceivedafamily-planning
service.
CostofinterventionSofar,overaperiodoftwoyears,thecostshavetotalledUS$40,943.Thisincludessupporttothe
integratedcommunityoutreach($3,700),monthlycoordinationmeetingwiththehealthcentrestaff
($12,300)andcapacitybuilding,includingtheVHTfunctionalityassessmentprocesses($24,943).
4.5Successfactors,gaps,challenges
Successfactors
• Anewfocusoncommunityhealth,especiallyas2015drawsnearandMDGs4and5arefarfromreachingtheir
targets.Now,withtheonemillionCHWsinitiativelaunchedinJanuary2013,thereisawindowofopportunity
forembracingCHWs.
Gaps
• LimitedknowledgeofCHWpolicies,evenamongcadresofthehealthsystemthataremeanttoprovide
guidanceandsupporttoCHWs,isasetbacktoensuringfunctionalityofCHWsystems.
Challenges
• Theapproachdoesnotevaluatethequalityofservicesdeliveredbyindividualhealthworkers.Themethodology
reliesonsecondaryevidenceandself-reportsforassessment;therefore,informationcollectedcannotbeused
toevaluateindividualCHWperformanceorCHWcontributionstocoverage,effectivenessorimpact.
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Our Contacts
World Vision InternationalEast Africa Region
KarenRoad,OffNgongRoad,P.O.Box133–00502Nairobi,Kenya
Forfurtherinformation:ContacttheHealthandNutritionLearningCentre
Email:sisay_sinamo@wvi.orgorjoan_mugenzi@wvi.org
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