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Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi
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Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi

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  • Since their initial design and implementation by World Relief in Mozambique in 1995, have been implemented in more than 25 countries by over 20 organizations

    Due to the intensive management and supervision requirements of Care Group activities satisfied through full-time paid staff, it may be difficult for communities and the MOH to sustain Care Groups following the conclusion of the program. The sustainability strategy for some Care Group projects may plan for CHWs or other community actors to take over the facilitation of the Care Groups after project completion, but this is understandably difficult if such actors have not received the proper training to facilitate the Care Groups and are not provided with a system for ongoing supervision and support.
  • With these project objectives in mind, we knew we’d be doing some kind of household level behavior change. We had done Care Groups in Rwanda and had visited WR’s CGs in Burundi.

    But we wanted to know whether there was a way for them to be integrated into the existing MOH system?

    Existing gov’t system looks like this

  • Integrated model was designed to reduce the dependence of Care Group implementation on full-time, paid NGO staff, while increasing integration with the local MOH structure. This is accomplished through task shifting of Care Group facilitation and supervision duties from project staff to appropriate MOH staff and CHWs, while still satisfying the established Care Group Criteria

    Still contained all the key activities of CG meetings, household visits, supervision, data collection as described earlier
  • Target = 80% based on global CG standards

    Looking for difference of 15% between two models
  • Transcript

    • 1. Integrating Care Groups into Government Structures: Learning from an Operations Research Study in Burundi Jennifer Weiss; Health Advisor, Concern US Delphin Sula; Health Program Manager, Concern Burundi Care Group Technical Advisory Meeting May 29-30 2014
    • 2. Overview of Presentation  Description of Concern’s ‘Integrated’ Care Group Model  Overview of Operations Research Study  Results of Operations Research Study  Learning and Implications
    • 3. Why Adapt the Model? What We All Know:  Care Groups have been implemented by more than 20 organizations in approximately 25 countries with excellent results  Evidence-based strategy that has significantly contributed to improved child health and nutrition outcomes.  Davis, T. et al (2013). Reducing child global undernutrition at scale in Sofala Province, Mozambique using Care Group Volunteers to communicate health messages to mothers. Global Health Science and Practice.  Edward, A. Et al (2007). Examining the evidence of under- five mortality reduction in a community-based programme in Gaza, Mozambique. Transactions of the Royal Society of Tropical Medicine and Hygiene. With Opportunity for Improvement…  NGO-lead model: what happens when the project ends?  Integration with Ministry of Health systems: increases opportunities for scale and sustainability
    • 4. Background to Child Survival Project • USAID CSHGP-funded project in Mabayi District, Cibitoke Province, Burundi • October 2008 – September 2013 • “Innovation” grant with OR component • Technical interventions: malaria, diarrhea, pneumonia, IYCF
    • 5. The ‘Integrated’ Care Group Model National level MOH Cibitoke Province Mabayi District Health Team Mabayi District Health Facilities (25) Community Health Workers (152, approximately 4 per health facility) Household level (estimated 107,000 WRA and CU5) Project Objectives: 1. Improved household maternal and child health care and nutrition practices 2. Improved access to quality child health care services with a balance of provision at the health center and community levels 3. Strengthened community leadership in health
    • 6. The ‘Integrated’ Care Group Model CHWs instead of Promoters Key difference: CHW only supervises 2 CGs DHT is trained by NGO staff to serve in ‘Supervisor’ role
    • 7. Operations Research Study: Methods Cluster randomized, pre-post study Traditional Area Integrated Area # Care Groups 51 45 # Care Group Volunteers 503 478 # Children Under 5 and Pregnant Women 7,758 6,630
    • 8. Operations Research Study: Questions 1. Does the Integrated Care Group model achieve at least the same improvements in key knowledge and practices as the traditional model? 2. Does the Integrated Care Group model function as well as the traditional model? 3. Is the Integrated Care Group model as sustainable as the traditional model?
    • 9. Care Group Activities Care Group Activities in Both Study Areas • Care Group Meetings 2x month • Facilitated by Promoter in Traditional • Facilitated by CHW in Integrated • Home visits to Neighbor Women at least 1x per month • Collection of household data (illness, death) MODULE TOPICS Nutrition  Definition and consequences of malnutrition and screening for malnutrition  Recognition of complications and danger signs of malnutrition  Nutrition and micronutrient supplementation during pregnancy  Immediate and exclusive breastfeeding for children 0-5 months  Complementary feeding for children 6-8 months and 9-23 months  Food groups (strength, energy, micro-nutrient)  Micronutrient supplementation for children Malaria  Malaria transmission, symptoms, and danger signs  Malaria in pregnant women: consequences and complications  Care-seeking for malaria Diarrhea  Diarrhea symptoms and danger signs  Home-based management of diarrhea  Hand-washing practices; how to build a tippy- tap  Water treatment and food hygiene Pneumonia  Definition, danger signs, and care-seeking  Home practices to prevent pneumonia Key Difference: Cascade Training in Integrated Area • Concern trains DHMT on modules • DHMT trains HF staff (quarterly) • HF staff train CHWs (monthly)
    • 10. Operations Research Results: Knowledge and Practices Indicator Type Example of Indicators Collected Total # % ‘non- inferior’ Knowledge  Danger signs in sick children  Critical times for hand-washing  Breastfeeding and complementary feeding practices  Food groups and components of balanced diet 13 85% Preventive Practices  Iron supplementation during pregnancy  Immediate and exclusive breastfeeding  Complementary feeding practices  Hand-washing  ITN use 13 100% Sick Child Practices  Diarrhea: care-seeking, use of ORS, increased fluids and food  Malaria: care-seeking within 24 hours, treatment with ACT  Pneumonia: care-seeking and treatment with antibiotic 10 90% Contact Intensity  Contact with trained health information provider  Attendance at community meetings where health of child was discussed 4 100% OVERALL 40 90%
    • 11. Operations Research Results: Functionality and Sustainability % of CG meetings with at least 80% Volunteer attendance
    • 12. Operations Research Results: Functionality and Sustainability % of HHs who received at least one visit by a CGV in the last month
    • 13. Summary of Results 1. The Integrated Care Group model achieved at least the same improvements in key knowledge and practices as the traditional model 2. The Integrated Care Group model functions as well as the traditional model 3. The Integrated Care Group model is as sustainable as the traditional model  In at least the six month period following end of project support to CG activities, project staff still active in area supporting other (non-Care Group) project activities such as CCM  Post-project sustainability study required
    • 14. Learning • CHWs are able to serve as Care Group Promoters through a modified model: • No more than 2 CGs per CHW • Monthly support (training and supervision) from health facility • Head nurses do not have time for Care Group / CHW supervision – delegate to a more junior nurse “focal point” • Integrated Model allows for community health data to be directly incorporated into Ministry HIS
    • 15. The ‘Value-Add’ of Integrated Care Groups In addition to increasing potential for scale-up and sustainability, Integrating Care Groups into the MOH structure:  Capacity building of MOH staff at all levels  Increase demand for CCM work by CHWs (identification and referral of sick children during home visits)  Reduction of workload of CHWs regarding the home visits  Improved link between the health facility and the community
    • 16. Policy Implications for Burundi MoH Some issues to take in consideration:  The start-up cost of Care Groups (Organization of CGV elections, basic and refresher training of MOH staff, CHWs and CGVs)  When national MOH should take the lead in training districts vs. NGO staff  The development and replication of the BCC modules, reporting tools (during scale-up – when the MOH has not yet taken up the approach fully)  Integration of other community health activities in CG???
    • 17. The Role of NGOs (medium term) Key role of the NGO in the Integrated CG model:  Support the district team for the start-up phase  Capacity building of the district team  Technical support to the district for the development of the BCC modules and registers  Financial support to the district team for the production of the BCC modules and registers  Advocacy at national level for the inclusion of the CG approach in the national community health policy
    • 18. What is Happening Now in Burundi?  Integrated Care Groups from original program still reporting to MOH and we are monitoring this data  Concern has funding to scale-up Integrated Care Groups in two additional districts (Ronald McDonald House Charities and UNICEF)  Extensive advocacy with MOH at national level to involve them from the beginning in establishing Integrated Care Groups (along with other Care Group implementers in Burundi – World Relief, FH, IMC, CRS)
    • 19. Conclusions • Traditional Care Groups have been proven to be effective in achieving coverage of key health and nutrition behaviors in numerous settings • CHWs are a growing part of Ministry of Health systems, however often difficult for CHWs alone to attain complete household coverage • Integrated Care Group model holds promise as a way to scale-up proven practices at the household level while leveraging existing structures, building local capacity Janvier Niandwi- Community Health Worker
    • 20. Thank you! For additional information: Jennifer Weiss Health Advisor Concern Worldwide, US Jennifer.weiss@concern.net Delphin Sula Health and Nutrition Program Manager Concern Worldwide Burundi delphin.sula@concern.net www.concernusa.org

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