93% retention of CHWs by end of project. Motivation of CHWs felt obligation to their community, appreciation by their community, pay 10,000 CFA per month, low (Future incentive based 10000 plus 5000 performance based)
Amount of time mothers waited before seeking HC after the onset of child’s illness. The 117( 49/6%) who waited less than 12 hours in the intervention group is clearly more significant that the 11 (10.2%) in the control (P<0.0001)
Before the presence of trained CHWs in the intervention area 67 (27.9%) of the 240 people (who now see trained CHW) resorted to self medication for their sick children. Indicating that new patients are being treated rather than patients just taken from HCs.
Accessibility to health care is significantly valued as a benefit of having CHW caring for children in Intervention area.
EOP Evaluation of BASICS iCCM Project Benin 2009 to 2012_Paul Freeman_4.25.13
EOP Evaluation of BASICS iCCMProject Benin 2009 to 2012USAID funded MSH implementedFreeman PaulDeussom GabrielParaïso M NoëlGlèlè Yolaine
Acknowledgements• USAID Washington and USAID Benin• Ministry of Health Benin & Staff, National, 5 HZs• MSH Basics staff Parakou• Project Partners 5 NGOs & Africare, UNICEF, CRS• Bryan Comstock U of Washington- sampling• Community members, surveyors, supervisors 6 HZDisclaimer. All views expressed are those of the authors and do notnecessarily reflect the opinion of USAID or the GH Tech team.Idea for CC study from USAID Benin but all design, implementationand write up by team.
Benin• Infant MR 73/1000 Child MR 115/1000 -2012• Malaria, ARI, diarrhea, anemia < 5 mortality• 47% of rural children < 5 stunted – 2012• 20% of rural children < 5 sleep under ITN-2012• Health Workforce Density < 0.05 /10,000p -2012FrancophoneTraditional MuslimPopulation9, 100,000 (2011)DemocracyLife E at B 56.8yrsFertility 5.1 c/w
Project Interventions• iCCM c.s. CHWs rural villages > 5 km from H. F.• Coordinate with MOH, UNICEF, Africare--CHW• Rx Malaria, ARI, diarrhea, refer/escort to HCs• CHWs home visits link mothers with HCs• CHWs ed about/support EPI, ITN• Supervisors/Educators/Drug Supply local HCs• Community based information system HCs• Local NGOs support CHWs –ESP remote areas
Project Site Northern Benin5 Health Zones93 Health Centers1048 CHWs trained193 trainer/supervisorstrained202,116 Infants less than 5yrs~16-20% of the under 5population of Benin5 local NGOs associatedwith the projectBegan :30 July 2009Ended : 29 Ju;y 201234 / 36 MonthsHZ TchaourouBORGOUHZ BassilaDONGAHZ Djougou-Ouaké-CopargoDONGACOVADESHZ HZ Kandi-Ségbana-GogounouALIBORIHANDICAP PLUSHZ BanikoaraALIBORICBBEGRADEDEDRASProject Cost: $ 4,377,056
Evaluation Questions• Coverage and quality of iCCM delivery• Capacity and sustainability of HZs and localNGOs to support CHWs• Achievement of project objectives & activities• Lessons learned and best practices.
Evaluation Methods• Three intervention HZ selected- Kandi, Tchaourou, Djougou• Key Informant Interviews- at all levels- MOH, local partner NGOs,UNICEF, Africare, CRS, others.• Focus Groups- CHWs, mothers, community• leaders, HC staff• Document review• Case Control study• Standardized Observation of Clinical Skills of 120 CHWsObservation Checklist Source. Adapted from Community basedDistributors Quality of Care Assessment IRC 2011
Case Control Study• 3 Intervention HZs compared w 3 control HZIn villages 5 to 10 km from local HC in South• 30 clusters of 10 mothers w children < 5 who hadfever, cough, or diarrhea in the past two weeksversus 30 clusters of 10 control HZ (600 total)• CHWs not trained in iCCM present in control.• Sampling power 80% to show differ > 10%• Standardized questions – trained interviewers
Total numbers of cases treated by CHWsNumber of Children agedLess than 5 yearsTreated by CHWsDuring project Treated for Male Female TotalMalaria 22357 19467 41824Diarrhea 2497 2220 4717Source .Project CHIS Cough/Pneumonia 3742 3461 7203
Household Homevisits by CHWs0500010000150002000025000300003500040000FY 2011 FY2012Household Visits by CHWs
Case Control General Results• Demographics of guardians same by sex, age• Mothers home only I 183 (63%) v C 110 (37%• Education no F.ED I 264 (86%) v C 181(62%• There were CHWs untrained in iCCM in control• 236 mothers sought HC for child from CHW inintervention area c/w 108 who sought HCfrom CHW in control
Time Delay Before Seeking Health CareIn Intervention And Control AreasINTERVENTION CONTROLDelay in seekinghealth careLess than 12 hours 117 (49.6%) 11 (10.2%) 12812 to 24 hours 77 (32.6%) 36 (33.3%) 11324 to 48 hours 25 (10.6%) 46 (42.6%) 71More than 48 hours 17 ( 7.2%) 15 (13.9%) 32N 236 (100%) 108 (100%) 344
Use Of Health Care Before The Presence Oflocal CHW Compared With ControlInitial Source ofhealth careINTERVENTIONCONTROL TotalHealthCenter147(61.25%)86(79.63%)223(66.95%)P =0.000Self-Medication67(27.92%)43(39.81%)110(31.16%P = 0.027TraditionalPractitioner3(1.25%)10 (9.265) 13(3.74%)P = 0.000N 240(100%)108(100%)348
Mothers’ Perception Of The Benefit OfHaving CHW Care For Their ChildrenProject CONTROL TotalCHWs live nearby 193(80.42%)76(70.37%)269(77.3%)P = 0.038Accessibility tohealth care177(73.75%)53(49.07%)230(66.09%)P < 0.0001Availability ofmedications130(54.17%)62(57.41%)192(55.17%)P = 0.57240(100%)108(100%)348
Mother’s perception of the quality ofcare given by CHWPERCEPTION INTERVENTION CONTROLCorrect treatment given byCHW90.5% 70.3%Satisfied with health caregiven97.5% 87%Access to follow up healthcare valued50% 23.1%
Skills of CHWs observed• Simulation of the examination a two old childpresenting with fever (Real mothers and child)The 119 RCs observed:• Asked– about the age of the child in 94%,– about fever in 93%,– about diarrhea in 82%, respiratory symptoms in 75.6%– and length of time of symptoms in 94% of cases.• Examination– 49.6% uncovered the child’s chest– 51% counted the child’s respiratory rate using a countingdevice.
Use of LLIN by Project Households•010002000300040005000600070008000Oct-10Nov-10Dec-10Jan-11Feb-11Mar-11Apr-11May-11Jun-11Jul-11Aug-11Sep-11Oct-11Nov-11Dec-11Use of LLIN by Households in the CommunityChildren having slept undera LLIN the previous nightHouseholds with a LLINconfirmed installed
Major Implementation Lessons• Collaboration – regular contact- CHW same• Local NGOs• Work AIDS – job, supervision, HIS HZ comp• CHWs locally chosen—CHW referrals followed• Local links-community-HC-HZ-central MOH• Collaborative supervision
Supervision Clinical Skills• July 2011 assessment of CHW clinical skillsfound widespread deficiencies• Collaborative Approach developed.• Individual coaching of CHW on-site and• during CHW visits to local HC using Check ListAt HC visits CHWs give one another feedback/help.Within each village local quality teams established towork with local CHW.
Performance of the CHWs andSupervisors in Clinical Assess. On FU.0102030405060708090100% FunctionalRC% SupervisedRC% FunctionalCoach% RC correctlyaskingquestions tosearch for GDSand GSEvolution of the Copargo Commune CHW performance within 6 months ofthe implementation of the Collaborative ApproachResults ObtainedPost Training Follow-upSupervision at 3 monthsSupervision at 6 months
Reasons Given for not using CHWsReasons given fornot using CHWIntervention Control TOTALNil answer given 15 (23.0%) 32 (16.8%) 47 (18.4%)Do not use them 19 (29.2%) 80 (42.1%) 99 (38.8%)Absence ofinformation aboutCHWs18 (27.7%) 55 (28.9%) 73 (28.6%)They are not available 13 (20%) 23 (12.1%) 26 (10.1%)N 65 (100%) 190 (100%) 255 (100%)