Complementary Evaluation for EIP and Documentation of

scale of Integrated Community Case Management in

Rwanda - Key Findings -

Presentation Outline

I. Background II. ObjectivesIII. MethodologyIV. ResultsV. Lessons LearnedVI. Next Steps

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Background

EIP CSHGP Program:

•Focused on iCCM, CHW training, supervision and supply chain

•Encouraging peer support through CHW Care Groups

Contributions to Scale:

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

•How did EIP contribute to pathway?

Cross-District Comparisons:

•How does the Care Group model compare with the existing default model of C-IMCI in Rwanda? And what lessons can be learned from its experience?

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Menu of Key Strategic Tasks by Timeline - MCHIPPre-introduction Definitive

decisionsIntroduction Early

implementationMature

implementationfrom unaware/ uninterested to

building consensus

consensus building to motivating

motivating to implementing

implementing implementing to sustaining

convene interested partners

begin change process

characterize problem/consider possible solutions

test/ refine approaches (pilot)

cultivate champions

secure official policy endorsement/ approval

secure financial commitments

formalize permanent working group

do detailed implementation planning

develop an M&E plan

develop training curricula & plans

procure needed drugs, supplies

address capacity issues

conduct orientations & training

ensure availability of drugs & supplies at point of service

monitor inputs, processes and quality

address barriers

address unintended consequences

maintain oversight

monitor fidelity

monitor and evaluate outcomes and impact

expand geographically

institutionalize

adapt as needed

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 3 different tasks.

Document Review (2001-2011)

Qualitative elicitation of narratives by 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)

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Interviews and FGDs ConductedTarget Done

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

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Technical persons 1 MOH11 NGO/Bilaterals

District Health Officer 1

Health professionals (Titulaire, CSC)

2

CHWs FGDs

Mothers / Caretakers

FGDs

Cooperative Officials FGDs

Fo

cus

Gro

up

Inte

rvie

ws

RESULTS 1: CCM Timeline in Rwanda

1990’s 2003 20102006 2007 2008

DIARRHEA

MALARIA

PNEUMONIA

POLICY

2005 20092004

EXPANSION

CHW CCM Cadre mooted

HBM TWG

IMCI TWG

Expansion of iCCM to 16 Districts 2008 (Phase 1)

HBM in all 19 endemic Districts

PHC

Pilot AQ at village level in 6 districts

HBM Strategic Plan

HBM in 6 Districts

Home-based fluid, ORS & Zinc in Kirehe

Oct 07: Bukora HC 1st ACT Tx by CHW

Feb 08: 1st Pneumonia case treated by a CHW in Kirehe

CH Policy + Community Health Desk

RDT Policy Change

C-PBF to incentivize CHWs

MCH CH TWG takes over from IMCI TWG.

Expansion of iCCM to 30 Districts 2009-2010

Rwanda CCM Timeline

Other Important Critical Events for CCM in Rwanda

Vision 2020 Umurenge of 2000 and Decentralization Policy of 2001

Global Fund Round 3, 5, 8, RCC

WHO TA for HBM 2004

HBM NGO pilot - CORE/PMI support 2004

Senegal Visit - 2006

BASICS TA for ICCM 2007

CHW Recognition by the Presidency - 2008

New Staff Cadre for CHW Supervision - 2010

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RESULTS 2: CHWs and Care Groups

The EIP intervened at critical points in the pathway to iCCM scale.

CHW Services are appreciated by both users and MOH.

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

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Potential CCM Challenges that Care Groups could help alleviate

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

Non-EIP Districts (without CHW Peer Support Groups)

Improving Task Competency for CCM e.g. use of timer, MUAC, RDT (Supervision/QA)

+ -

Minimizing stock-outs by sharing inventory (Motivation)

+ -

Technical Supervision by Peers

+ -

Pooling/ Sharing Cases among CHWs to maintain CCM proficiency

+ -

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Lessons Learned: MCHIP’s Considerations

MCHIP validated the hypotheses it was testing. Now to consider

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

- testing different CHW restocking models/ supervision models

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Next Steps

Compare 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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