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

Overview of Presentation

Description of Concern’s ‘Integrated’ Care Group Model

Overview of Operations Research Study

Results of Operations Research Study

Learning and Implications

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

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

The ‘Integrated’ Care Group Model

Project Objectives:1.Improved household maternal and child health care and nutrition practices2.Improved access to quality child health care services with a balance of provision at the health center and community levels3.Strengthened community leadership in health

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

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

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?

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)

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

discussed4 100%

OVERALL 40 90%

Operations Research Results: Functionality and Sustainability

% of CG meetings with at least 80% Volunteer attendance

Operations Research Results: Functionality and Sustainability

% of HHs who received at least one visit by a CGV in the last month

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

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

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

Policy Implications for Burundi MoHSome 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???

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 teamTechnical 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 registersAdvocacy at national level for the inclusion of the CG approach in the national community health policy

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)

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

Thank you!

For additional information:

Jennifer WeissHealth Advisor

Concern Worldwide, US Jennifer.weiss@concern.net

Delphin SulaHealth and Nutrition Program Manager

Concern Worldwide Burundidelphin.sula@concern.net

www.concernusa.org