Partnership with MOH: Rwanda

1. Rachel Hower, World Relief
CORE Group Spring Meeting
May 18, 2016
Partnership with MOH:
Rwanda

2. World Relief and Rwanda MOH in
Partnership:
• Umucyo “Light” Child Survival Project (2001-
2006)
• Kabeho Mwana “Life for a Child” Expanded
Impact CSP Concern Worldwide, IRC, World
Relief (2006-2011)
• Tangiraneza “Start Well” Innovation Child
Survival Project (2011-2015)

3. World Relief’s Umucyo CSP (2001-2006)
• Location: Nyamasheke District,
Western Province, Rwanda
(Former Kibogora Health District)
• Total Population: 152,981 people in 29,166 HH
• Care Groups: >2800 Volunteers in 202 Care Groups;
HH visits 2x/mo;
10 HH per Volunteer;
Trained by project staff

4. Umucyo Major Activities
• C-IMCI for 6 Interventions:
– Malaria, HIV/AIDS, Nutrition and
BF, Diarrhea, Immunization, and
MNC;
• Piloted and scaled up Home
Based Management of Fever
(e.g. CCM for suspected
malaria) with grant from CORE
Group (partnering with MOH,
Concern and IRC)
• Also formed “Pastors Care
Groups” from 11 church
denominations

5. Umucyo Results – Malaria
Pregnant Women Who Slept Under an ITN Last Night
0%
20%
40%
60%
80%
100%
Baseline KPC Midterm KPC Final KPC Rwanda DHS
2001 2004 2006 2005

6. Umucyo Project Impact:
Estimated Annual Mortality Reduction using LiST
Using the Lives Saved Tool (LiST) to estimate mortality
impact of the project, the annual U5 mortality rate
decreased by 7 per year in the project area.
In contrast, sub-analysis of the DHS found that U5
mortality in the same region was getting worse – U5
Mortality increased by 3.4 per year.
Source: Community-based intervention packages facilitated by NGOs
demonstrate plausible evidence for child mortality impact. (Health Policy and
Planning, 2013: 1-13. Jim Ricca, Nazo Kureshy, Karen LeBan, Debra Prosnitz, and
Leo Ryan)

7. Umucyo: Partnership with MOH
Good relationship (district level)
• EOP: MOH requests continued WR support of CGs
• WR response: 1 staff per HF to support community
health. Salaries transitioned to HF within one year.
• Some of these positions are still in the HF today. 60% of
CGs still exist in Kibogora. Many volunteers are CHWs now.
Collaborative: CCM (national implications)
• CCM scaled up to 6 districts in EIP
But NOT Integrated
• Parallel Structure: NGO staff trained community volunteers

8. Kabeho Mwana Expanded Impact CSP
Concern Worldwide, IRC, World Relief (2006-2011)
Location: 6 districts in Southern
and Eastern Rwanda
Total Population: 1.67 Million
Project Focus:
• Support to MOH Scale up of
iCCM (Diarrhea, malaria, pneumonia)
• Promotion of Key Family
Practices – using Care Groups
(we thought)
MOH Mandate:
Work only with Government
CHWs

9. CHWs in Rwanda
4 CHWs per Village at time of project
2 CHWs (Male-female ‘binome’) for iCCM
1 CHW for Maternal Health (female)
1 CHW for Social Affairs (male or female)
Workload: Each CHW is responsible for the entire
village (60-80 HH), focused on their technical areas of
specialty. Emphasis on treatment over household
behaviors.
Supervision: The Community Health In-Charge at the
Health Center is responsible for supervision of CHWs.

10. Challenges for iCCM
• Regular, supportive supervision
to large numbers of CHWs
• Balancing treatment and
prevention
• Integration of services by
different providers
• Refresher trainings with every
protocol change ($$)
• Increasing CHW workload

11. Care Groups  CHW Peer Support Groups
• CHWs from 2-5 neighboring villages organized
into “Peer Support Groups” at cell level with up to
20 members, about half of whom were male.
• CHWs of all types were “cross-trained” in BCC,
while maintaining their specialized functions
• CHWs from the same village divided up
households (15-20 per CHW) to better support
monthly home visits for BCC.
• 3 Project Promoters per district built capacity of
CHW Cell Coordinators (elected by their peers) to
help with training and supervision of groups.
Violates Care Group Criteria  Peer Support Groups
http://caregroups.info/

12. Initial CHW Supervision System for iCCM
Health Facility-based
In-Charge of Community
Health
Many CHWs (50 – 150) under the supervision of one
facility-based supervisor for iCCM
One hour – one day walk from
villages to the health facility

13. CHW Peer Support Groups
CHW
Group
CHW
Group
CHW
Group
CHW
Group
CHW Cell Coordinator
Health Facility-based
In-Charge of Community Health
Slide courtesy of Jennifer Weiss, Concern Worldwide

14. Scale of Peer Support Group Training/
MOH Partnership: Integrated Structure
• Small number of NGO staff train MOH CHWs
• Helped MOH train 13,166 CHWs (including those trained in
CCM) to mobilize the community and conduct monthly
home visits for Health Promotion & Data Collection
• Helped the MOH to train and support over 6,100 CHWs and
88 HCs in iCCM according to national guidelines
– ACTs for Malaria (later adding RDTs)
– ORS and Zinc for Diarrhea
– Amoxicillin for Pneumonia
• Helped develop health promotion materials for key
household behaviors, used nationally.

15. Knowledge, Practice & Coverage (KPC)
Household Survey Results:
Malaria, Pneumonia & Diarrhea Treatment
20%
0
15%
5%
43%
54%
33%
22%
0%
10%
20%
30%
40%
50%
60%
Fever Tx Seeking
& Appropriate
Care in <24
hours
Children with
pneumonia
treated by CHW
with amoxycillin
ORT use for
diarrhea
Zinc Tx for
diarrhea
Baseline
Final

16. Health Promotion
2%
22%
36%
19%
57% 57%
0%
10%
20%
30%
40%
50%
60%
Hand washing with
soap/ash at key times
Continued feeding
during illness
Increased liquids
during diarrhea
Baseline
Final

17. Treatment seeking from a trained provider for an episode of
diarrhea, ARI or fever in children under five in the two weeks prior
to the survey, by project or non-project area (DHS re-analysis)
Source: Langston et al. Glob Health Sci Pract 2015;3(3):358-369

18. U5 Mortality Impact
– per DHS reanalysis
Geographic
Area
% Decrease DHS 2005 DHS 2010
Nationally 50% 152/1,000 76/1,000
6 Project
Districts
55% 183/1,000 83/1,000
Non-Project
Districts
49% 144/1,000 74/1,000
Under-five mortality rates decreased more in
the Kabeho Mwana-supported districts than in
non-project districts.

19. Partnership and Integration:
Supporting MOH Community Health Strategy
• Helped CHWs integrate and coordinate their
activities, including iCCM
• Scalable (but not nationally adopted)
• Innovative solutions to implementation
challenges fit in existing MOH infrastructure:
– CHW cell coordinator for peer supervision; now
implemented nationally
• Strong leadership from the MOH: quickly scaled
up iCCM nationally
• Health Promotion Materials used nationally

20. Tangiraneza “Start Well” Innovation
Child Survival Project (2011-2015)
Location: Nyamagabe District
Total Population: 330,510
17 Sectors, 92 Cells, 536 Villages.
Project Focus:
• Support Ministry of Health with
community health interventions
– Nutrition - 40%
– Maternal Newborn Care - 35%
– Diarrhea - 15%
– Pneumonia - 10%
• BCC reinforced through integrated
Care Groups comprised of
community health workers (CHWs)
and village leaders.
• Operations Research on nutrition to
reduce stunting

21. Integrated Care Group Model:
Village Level
CHWs +
Village Leaders
Care Group
CHW Cell
Coordinator
Households
HC In Charge
Sector In Charge
Social Affairs
Cell In Charge of
Social & Econ
Development
Community leaders:
• Religious Leader
• Elected Village leader
• Hygiene Club Representative
• Women’s Group Leader
• Village Social Affairs In Charge
• Village Information & Training In Charge
• Village Community Development Leader
CHWs:
• Binome
(M&F)
• ASM
Integrated
Care
Group
Continued Integration, tweaked

22. Extending the reach of MOH:
CHW Training, Supervision, Home Visits
• Regularly trained 1470 CHWs (MCH
and RH )
• HC staff supervision to 28% of CHWs
per month, average (goal 30%)
• 536 Integrated CGs (5114 members)
provide BCC during HH visits for BCC
and ICCM
• Enhanced Nutrition Activities (OR):
– ‘Nutrition Weeks’ in Kaduha
– Improved GMP sessions in Kigeme

23. Result Highlights –Infant and Young Child Feeding
Minimum Acceptable Diet
0
20
40
60
80
100
Y1 Y2 Y3 Y4
Kaduha Kigeme
Minimum Meal Frequency
0
20
40
60
80
100
Y1 Y2 Y3 Y4
Kaduha Kigeme
Introduction of semi-solid foodBreastfeeding within 1 hour of birth

24. Other Result Highlights
ANC in 1st trimester
0
20
40
60
80
Baseline Final
Kaduha Kigeme
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Final
PNC within 2 days of birth
Kaduha Kigeme
Care seeking for suspected pneumoniaSoap at Handwashing Stations

25. Keys to Partnership
• Relationships at all levels (HC, hospital,
district, central)
• Understanding competing priorities and time
constraints
• Importance of both technical and
administrative partnership
– Annual OR approval, annual registration (workplan
review)
• Involve the community leaders with the
project at all stages, and follow through on
plans.

26. Thank You