improving the health and nutrition status of women and children

Improving the Health and Nutrition Status of Women and Children

Promising Practices from East Africa

May 2013

Improving the Health baby september24-evening.indd 1 9/27/13 8:14 AM


Acknowledgments

• HealthstaffatAlamataTownHealthCentreandDistrictHealthOffice

• WorldVisionEthiopiaMekeleProgramOffice

• Communityhealthworkers,hillleadersandhealthcentrestaff

• WorldVisionBurundinutritionandhealthstaff

• Healthworkers,communityhealthworkers,DistrictHealthManagementTeamandWorldVisionstaffat

BondoDistrict

WorldVisionisaninternationalpartnershipofChristianswhosemissionistofollowourLordandSaviourJesus

Christinworkingwiththepoorandoppressedtopromotehumantransformation,seekjusticeandbearwitnessto

thegoodnewsofthekingdomofGod.

Documentationteam:JoanMugenzi,WorldVisionEastAfricaRegionHealthandHIVMonitoringandEvaluation

Specialist,andDr.SisaySinamo,WorldVisionEastAfricaRegionNutritionAdvisor

©WorldVisionInternational2013

Allrightsreserved.Noportionofthispublicationmaybereproducedinanyform,exceptforbriefexcerptsin

reviews,withoutpriorpermissionofthepublisher.

PublishedbytheEastAfricaRegionHealthLearningCentreonbehalfofWorldVisionInternational.Forfurther

informationaboutthispublicationorWorldVisionInternationalpublications,orforadditionalcopiesofthis

publication,[email protected].

SeniorEditor:HeatherElliott.ProductionManagement:KatieKlopman,DanielMason,DuncanMutavi.

Copyediting:AudreyDorsch.Proofreading:AmberHendrickson.Designandlayout:[email protected]

Coverimage:JoanMugenzi/WorldVision


1


Contents

Executive summary.......................................................................................................................................................2

General introduction to the booklet.................................................................................................................3

1. Traditional Birth Attendants (TBAs): Embracing TBAs and cultural practices for

increased uptake of health facility services in Alamata District, Ethiopia......................5

1.1 Rationalefortheintervention.........................................................................................................................5

1.2 Interventionobjectives.......................................................................................................................................6

1.3 Keyactionstaken.................................................................................................................................................6

1.4 Achievements........................................................................................................................................................7

1.5 Successfactors,gaps,challenges.....................................................................................................................9

2. Focal Nutrition Learning Centres: Using locally available resources

to improve child nutrition in Burundi..................................................................................................... 11

2.1 Rationalefortheintervention........................................................................................................................ 11

2.2 Interventionobjectives.....................................................................................................................................11

2.3 Keyactionstaken............................................................................................................................................... 11

2.4 Achievements......................................................................................................................................................13

Casestudy1:WorldVisionfieldexperienceanditscontributiontothedevelopment

ofnationallevelFARNguidelines......................................................................................................................................16

2.5 Successfactors,gaps,challenges...................................................................................................................16

3. Defaulter tracing: Using defaulter tracing for essential maternal and child

health (MCH) services in Bondo District, Kenya.............................................................................19

3.1 Rationalefortheintervention........................................................................................................................19


3.3 Keyactionstaken...............................................................................................................................................20

3.4 Achievements......................................................................................................................................................23

Casestudy2:ANCandImmunisationsupportgroupsatGotMatarHealthCentre........................................25


4. Community health worker functionality assessments: A means to strengthen

the health system in the region...................................................................................................................28

4.1 Rationalefortheintervention........................................................................................................................28


4.3 Keyactionstaken...............................................................................................................................................28

4.4 Achievements......................................................................................................................................................29

Casestudy3:KitgumDistrictinUgandabenefitsfromtheCHWsystemsstrengtheningapproach............30



2


2

Executive summary

Since2012,theWorldVisionEastAfricaRegionHealthandNutritionteamhasembarkedonengagingwithnational

officestoidentify,documentandsharepromisingpracticesofainterventionsthathavehaddemonstratedimpactin

thecommunitieswhereWorldVisionworks.ThisisinlinewiththekeymandatesofLearningCentres.

ALearningCentre(LC)is‘agroupofpeoplewithrecognisedcapabilityinaspecificdiscipline,locatedinastrategic

nationaloffice,whodefinebestpracticesanddisseminateknowledgethroughouttheregionthroughface-to-faceand

virtualcollaboration,withafocusondrivingresults.’1

Theoverallobjectiveofknowledgemanagementpracticeistocapture,disseminate,andpromotetheuseofinternal

andexternallearningonhealthandnutritionprogrammes.WorldVisioncontinuestoseektheenhancementofthe

qualityandprofessionalismofitsprogramming,withthecapturingandexchangeofknowledgebeingkeytothiswork.

Inthisbooklettheteamsharesfourpromisingpracticesfromwhichnationalofficescanlearnandlessonswhichthey

canincorporateintohealthandnutritionprogramming.Thefourpracticesare:

• TraditionalBirthAttendants(TBAs):EmbracingTBAsandculturalpracticesforincreaseduptakeof

health-facilityservicesinAlamataDistrict,Ethiopia

• FocalNutritionLearningCentres:UsinglocallyavailableresourcestoimprovechildnutritioninBurundi

• Defaultertracing:Usingdefaultertracingforessentialmaternalandchildhealth(MCH)servicesinBondo

District,Kenya

• Communityhealthworkerfunctionalityassessments:Ameanstostrengthenthehealthsystemintheregion.

Thesepracticeshighlightsimpleinterventionsthathaveledtopositiveoutcomesinantenatalcareservices

uptake,skilledbirthattendance,nutrition,growthmonitoringandpromotion,immunisationuptake,and

benefitsaccruingfromacommitmenttohealthsystemsstrengthening.

Foreachofthepractices,thisbooklethighlightstherationalefortheintervention,interventionobjectives,keyactivities

takenandachievements.Italsonotessuccessfactors,gapsandchallenges,presentingagreatlearningopportunity.

Casestudiestoillustratebenefitsofsomeinterventionsarealsoincluded.

1 Africa LC High Level Operating Model V6(2010)(internaldocument).


elliotth

Highlight

3


WorldVisionInternationalhasprogrammesinninecountriesin

EastAfricathathaveacombinedpopulationofover247million.

Theregionhasunacceptablyhighinfantandunder-5mortalityrates,

at101and181per1,000livebirthsrespectively.Affordablehealth

interventions,whenmadeavailabletothemothersandchildren

whoneedthem,willpreventanestimated6.6millionchilddeaths

worldwideandtheMillenniumDevelopmentGoalnumber4,reduce

childmortality,couldbeachievedby2015.2

ChildmortalityinmostcountriesinEastAfricahasshowna

decliningtrendinpastdecades.However,bothneonataland

maternalmortalityhavelargelyremainedthesame.InEastAfrica,

neonatalmortalityaccountsfor22–31percentofunder-5deaths.

Sadly,progressinreducingdeathshasbeenslowerfornewbornsthanamongchildrenaged1monthto5years.3

Eachyearthousandsofwomendieinchildbirthorfromcomplicationsduringpregnancy.Ethiopia,Tanzania,Kenya,

UgandaandSudanareamongthe21countrieswiththemostmaternalandunder-5deathsin2008.

Chronicmalnutritionisadevelopmentalproblemandsilentemergencyinallcountriesintheregion.Thisis

worsenedbythehumanitarianemergency,whichthreatensthelivesofchildrenandtheaffectedpopulationinthe

region.ArecentDemographicandHealthSurvey(DHS)reportin2011showedthattheprevalenceofstuntingis

ashighas58percentinBurundi;underweightremainedacriticalpublichealthproblemintheregion(inEthiopia

underweightprevalencedeclinedfrom41percentto29percentbetween2000and20114);andwastingremained

highinchronicallyfood-insecureareassuchasSomalia,KenyaandsouthSudan(15percentto23percent).5

Accordingtothesamereport,anaemiaisthemajornutritionaldisorderamongchildrenandpregnantwomeninthe

region,resultinginadversepregnancyoutcomesaswellasunderweightbabies.

CountriesinEastAfricaRegionhavemadegoodprogressinthefightagainstHIVinfection.Inthepastdecade,the

prevalenceofHIVhasdroppedbymorethan40percentinanumberofcountries.Ugandahadmadegoodprogress

butnowseemstobelosingthebattle;around2007,theprevalencewas4.3percentbutthathasnowrisento

7.3percent,thehighestintheregion.Somaliahasthelowest,at1.4percent.6Inspiteoftheprogressmade,the

prevalenceisunacceptablyhighacrosstheninecountries.

2 GlobalHealthCouncil,A Global Health Council Position Paper on Child Health(2007).3 Countdownto2015,Countdown to 2015: Decade Report(2000–2010).4 EthiopianDemographicandHealthSurvey(2011).5 UNICEF,Progress on Child and Maternal Nutrition(2009).6Countryprogressreports2012(internaldocuments).

General introduction to the booklet


4


TheoverallgoaloftheEastAfricaregionalhealthnutritionandHIVandAIDSstrategyistocontributetothe

improvementofthehealthandnutritionalstatusofwomenandchildreninWVoperationalareas,workingin

partnershiptodevelopthecapacitiesofnationaloffices(NOs)todesign,implementandmonitorhighimpactand

cost-effectivehealth,nutritionandHIVandAIDSprogrammes.

Since2012,theEastAfricaRegionhealthandnutritionteamhasbeguntoengagewithNOstoidentify,document

andsharepromisingpracticesofinterventionsthathavemadeadifference.Fourpracticesarepresentedinthis

booklet.SomeofthesepracticeshavefullybeenpublishedbytherespectiveNOs(e.g.Burundi);dissemination

eventsforthesepracticeshavebeenheld(EthiopiaandRwanda);andlearninghasbeengleanedfromwhatother

partnersaredoing(defaultertracingforessentialservicesinBondoDistrict,Kenya).

Theregionhasdecidedtoworkstrategicallythroughthecommunityhealthsystem,andsinceNovember2011,

hassupportedNOstoconductcommunityhealthworker(CHW)assessmentsasawayofcontributingtowards

healthsystemsstrengthening(HSS).HSSisahealthandnutritionstrategicapproachfocusingonequippingCHWs

tofacilitateimplementationofcorehealthandnutritioninterventions.Inthisbookletweshareourexperience

conductingtheassessments,andweprovideacasestudyfromUgandashowingprogressfollowinginvestmentsin

communityhealthstructures.

Wehopethisbookletwillbebeneficialtoyou.Manythankstoourteammembers,JoanMugenziandSisaySinamo,

fortakingtheleadonthisexercise,andtothevariousnationalofficeteamsthatcontributedtothecompilationof

thisbooklet.

MesfinLoha

Director,HealthandHIVandAIDS


5


1.1Rationalefortheintervention

AlamataTownDistricthealthcentreisoneof47districtfacilitiesthatfallundertheMekelleRegionalHealthBureau

inthenorthernpartofEthiopia.ItislocatedintheSouthernTigrayZone.Amongtheeightdistrictsinthiszone,

AlamataTownDistrict,whichservesapopulationof37,600people,emergedastheworstinstitutionaldelivery

healthserviceproviderforfourconsecutiveyears(2005–2008).Thehealth-facilitydeliveriesinthisareawere

appalling,astheregionalhealthbureaunoted.

TheAlamataTownDistricthealthofficenotedthelowratingbuttooknoactiontoimprovethesituation.Itwas

cleartherewasgoodantenatalcare(ANC)duringthefirstandsecondtrimestersofpregnancybutlowinstitutional

delivery.

PartofAlamata’sexplanationforpoorperformancewasthepossibilityofpoorcounselling.Theythoughtof

preparingpostersoninstitutionaldeliverybutdidnotactonthat.

ThisscenarioledtheheadoftheMekelleRegionalHealthOfficetocommentthattheAlamatafacilitywasbetter

off‘keepingcattle,’observingthattherewasnoservice.TheAlamataTownDistricthealthofficereceivedthis

commentinthemidstofalackofequipmentanddeliverytools.

Theregionalfeedback,alongwithathreattoclosethefacilityifthepoorperformancecontinued,becameawake-

upcallfortheAlamataTownDistricthealthservicestotakeactiononthegaptheywerealreadyawareof.Although

therewasanongoingplanandachievementreviewandreflection,thelowperformanceremainedduetolackof

readinessamongthehealthworkerstochangethesituation.Laterthehealthworkersstartedtoidentifysolutions,

oneofwhichwaslinkingwiththecommunityhealthworkersandnursehealthextensionworkers(HEWs),which

helpedthehealthworkerstoplanandachievebetterperformance.

Amongthekeyactionswasastudyoninstitutionaldeliveryinthecommunity.Thestudy,carriedoutinJune2010,

found53childrenwithoutimmunisationand169pregnantwomenwithoutANCfollow-up.Discussionswereheld

withthemothers,andhealthworkersidentifiedpertinentissuesthatcalledforattention.

Keyissuesraisedbymothersweretheperceptionsthat:

• onlywomenwithproblemsdeliverathealthfacilities

• therewasashortageofstaffatthehealthfacilities

• thedeliveryenvironmentwasunhygienic,carryingtheriskofHIVduetocontamination.

Healthpersonnelalsoidentifiedpositiveculturalpracticesandbeliefsthatkeptwomenpreferringtodeliverat

home.Suchpracticesincludedthecoffeeceremonyattheonsetoflabour,preparatorymaterialssuchasutilities

formakingporridge,celebrationofthebirth,andthespiritualrelevanceofcallingonMotherMaryatthetimeof

delivery.

Besidesthesepracticesandbeliefs,theservicechargeandtheabsenceofdeliveryservicesatthehealthcentre

duringoff-dutyhours(5p.m.–8a.m.)wereotherhindrancestosomemothers.

Althoughthehealthworkersbelieveditwasnotpossibletochangethesituation,onesupervisorproposedtheidea

ofbringingpregnantwomenandtraditionalbirthattendantstogethertochangethesituation.Theresponsefrom

someofthecolleagueswas,‘Isitpossible?’Withhesitationtheideawasmovedforward,andlaterothercolleagues

startedtosupportitandadistrictgoalwassettoseemothersdeliveringinthehealthfacilities.

1 Traditional Birth Attendants (TBAs): Embracing TBAs and cultural practices for increased uptake of health-facility services in Alamata District, Ethiopia


6


1.2Interventionobjectives

• Toreducehomedeliveriesto0percentintheshortesttimepossible

• Toensurethatnomotherdiesfromlabouranddelivery,accordingtotheMillenniumDevelopmentGoal

(MDG)

1.3Keyactionstaken

Toachievethedesiredobjectives,thedistrictundertookvariousactions,includingthefollowing:

• Conductedasurveytoidentifypregnantwomeninthetown.Theyfoundatotalof169pregnantwomen(of

whom93hadTetanusToxoid1and4hadTetanusToxoid2).Inaddition,theyidentified53childrenwithout

age-appropriateimmunisationcoverage.Thestudyalsohelpedthedistricthealthservicestoestablishmothers’

understandingofthebenefitsofinstitutionaldeliveryandissuesrelatedtoit.

• ApproachedWVforsupport,whichenabledthemtoacquireskillsthroughtrainingoftraditionalbirth

attendantsandawareness-raisingamongthemothersontheimportanceofinstitutionaldeliveriesandthe

supportivesupervisiononsite.

• Providedtrainingtopregnantwomenatthehealthcentre.Itincludeddiscussionsonthebenefitsofinstitutional

deliveryandrisksofhomedelivery,suchasHIV,bleeding,etc.Thetrainingalsoincorporatedanunderstanding

ofthehealthcentreenvironment,includingshowingthecleanlinessofthedeliveryroomandproviding

testimonialsfrompregnantwomenlivingwithHIV.Allthewomenwhoattendedthetrainingreceivedtetanus

toxoid(TT)immunisationandlong-lastinginsecticide-treatednet.In2010noneofthewomen’sspouses

participatedinthetraining,soin2011spousesweredeliberatelytargetedtobepartofthetraining.This

trainingalsocreatedabetterunderstandingoftheproblemsathand,andmotherswerealsoabletounderstand

theservicesoffered,therisksofhomedeliveryandthebenefitsofinstitutionaldelivery.

• Trained27traditionalbirthattendants(TBAs)and1,165HealthDevelopmentArmy(HDA)workers:this

assistedthehealthofficetointegratetheTBAsintheHDA.AnHDAisagroupofvolunteersselectedfromthe

communitytopromotehealthservicesforfivehouseholdsinthecommunity.Notethatthe27TBAstrained

werepartoftheAlamataTownDistricthealthservicespriortothefacilitytakingdeliberatestepstoimprove

institutionaldeliveryservices.Afterthetraining,TBAsagreedtocounselandaccompanypregnantwomen

tothehealthfacilitiesfordelivery.OneofthekeysuccessstoriesofthisprocesswashavingtheleadTBA,

famousforhomedeliveries,referpregnantwomentothehealthfacilities.TheTBAswereattachedtoHEWs

forsupervisionpurposes.ThetelephonenumbersoftheHEWsandtheambulanceweregiventotheTBAsfor

easycontact.

• Discussedservicedeliveryimprovementsatthefacilitylevel.

• Increasedthehealthcentreandhospitalfocusoncleanliness,referralforuseoftheambulanceavailableat

thehospital,trainingofhealthstaff(onemidwifeandonenurse),provisionoffreehealthservicedeliveryto

pregnantwomenandlactatingmothers,introductionofemergencyobstetriccareatthehospitalandinitiation

ofdeliveryservicesatthehealthcentre.ThroughWVandothersources,theyacquiredcriticalmaterialssuch

asadeliverycouchandMCHdrugs.


7


• Withdrewtheserviceofprovidingandrefillingdeliverykits(gloves,soap,GentianViolet,Tetracycline,

eyeointment,cotton,etc.)totraditionalbirthattendantstopromoteinstitutionaldelivery.Thedistrict

healthofficeworkedincollaborationwiththeReliefSocietyofTigraytoprovideincentivesforTBAsinthe

community.

• Institutionalisedculturalpracticesthatdonotaffectthehealthofthemotherorthedeliveryoutcome,suchas

thecoffeeceremony,celebratingthebirthofthechildandplacingapictureofSaintMaryinthewaitingandthe

deliveryrooms.

• Workedonwaysthehealthworkerswouldhandlemotherswhentheycomefordelivery.Thisledtobetter

practicesandbehavioursamongthehealthworkers,suchascourtesy,creatingabetterdeliveryenvironment

andimprovingthelinkagewithHEWsandtheHDA.

• Documentedallthepregnantwomenineachofthekebeles(villages);thesearecontinuallyfollowedupto

thepointofdelivery.Thisearlyidentification,registration,referralandfollow-upofmothersmadeagreat

contributiontouptakeofservices.

• Trackedandmonitoredtheperformanceofkebele-levelHEWs.

• Sensitisedthetraditionalandkebeleleadersontheneedforinstitutionaldeliveryandtheleadershipsupport

theycouldprovide.

• ImplementedtheHDApolicy,whichtheEthiopiangovernmentintroducedaroundthetimeofimproving

institutionaldeliverieswithinthedistrict.TheWomenDevelopmentArmies(WDAs)arecommunity-selected

volunteersandmodelmotherswhohaveabetterunderstandingandpracticeofthehealthextensionpackages.

Thehealthextensionpackagecomprises16interventionstargetingthehousehold(HH)level.TheycoverMCH

(includingnutrition),hygiene,sanitation,andinfectiousandcommunicablediseases.EachWDAleaderhas

responsibilityforfivehouseholds.Theyknowwhichmothersarepregnantandtheyreferthepregnantwomen

totheextensionworkers.Currentlyhealthworkerscontinueongoingassessmentofpregnantwomenand

lactatingmothers.Mothersreceivepreventionofmother-to-childtransmissionofHIV(PMTCT)services,and

afterdeliverytheyarereferredforimmunisationservices.CommunityHEWsalsoregisterallpregnantwomen,

documenttheexpecteddeliverydateandfollowupathome(atleast90percent).

Thedistricttappedintothisopportunitytointegratethe27previouslyactiveTBAsintotheHDAstructure.Rather

thansupportthemtoconductdeliveries,thedistrictfocusedontrainingthemonkeymaternalissuesandturned

themintomobilisersforhealth-facilityserviceusage–discussingthebenefitsofinstitutionaldeliveriesandrisksof

homedeliveries.

1.4Achievements

AlamataTownDistricthealthservicesregisteredvariousachievementsthatresultedinthedistrictprogressingfrom

theworst-performingdistrictintheSouthernTigrayZonetothebest-performingdistrict.Belowarehighlightsof

achievementsandtrends.


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Antenatalcareandinstitutionaldelivery

• FollowingthetrainingofmothersandTBAsandthesensitisationofthecommunitygroups,asustained

increasewasobservedinthenumberofmotherscomingtothehealthfacilitiesfordelivery.Emphasison

institutionaldeliveryalsoledtoanincreaseintheuptakeofANCafteroneyearofintervention;there

wasaslightdropinyeartwoandanincreaseinyearthree.(SeeFigure1.)

Figure 1: Trend of ANC and institutional delivery in Alamata Town District (2008-2011)

ANC

Institutionaldelivery

2008

1,400

1,200

1,000

800

600

400

200

0

2009 2010 2011

Year

Nu

mb

er

• Accordingtokey-informantinterviewswithhealth-facilitypersonnel,itisestimatedthathomedeliveries

havedeclinedfrom50percentto7percent.Dataforhomedeliveriescannotbegeneratedfromthehealth

managementinformationsystem(HMIS)becauseTBAactivitieswerescrappedfromtheHMIS.Health-

facilitydatashowedtherewasaclearimprovementinuptakeofANCandinstitutionaldeliveryservices,with

anincreaseof72.5percentinANCservicesand246.9percentincreaseindeliveries.Figure2showsthe

performanceinAlamatatownpriortotheinterventionin2008andagainin2011,whentheanalysisofthepost

interventionwasdone.

Figure 2: Baseline and post-intervention in Alamata Town

2008

2011

ANC

743

1,400

1,200

1,000

800

600

400

200

0

687

Delivery

Year

198

Nu

mb

er

1,282


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Preventionofmother-to-childtransmissionofHIV

• ThenumberofwomenwhoknowtheirHIVstatushasincreased.AllwomenwhoattendANCaretestedfor

HIV,andthosewhoarefoundpositiveareregisteredforPMTCTandlinkedtooneofthefiveHIV-positive

mother-supportgroups.BasedontheJuly2011annualDistrictHealthOfficereport,860womenwereenrolled

forPMTCTservices,comparedwithonly38womenin2008.Thishighlevelofenrolmentcanbeattributedto

thedeliberateidentificationandfollow-upofpregnantwomenforhealth-facilityservices.

MothersandfamilyinvolvementtosupportMCHusage

• Mothersindicatedthattheyareadvisingothermotherstodeliverinhealthfacilities.Theyalsoreportedthat

theydiscussedthebenefitsofMCHserviceswiththeirpartnersandaskedfortheirtosupportinusingthe

services.Mothersarehappyfortheirownandhealthworkers’roleinpreventingillnessessuchasHIVand

ensuringdeliveryofhealthychildren.

• Regardinginclusionofmeninfamilyinvolvement,TBAsreportedthatduringtheWVtrainingwomenwere

alsoencouragedtoeducatetheirpartnersonANCandinstitutionaldelivery.TheHDAalsoencouragesmen

totakecareofwomenduringhomevisits.ParticipationduringPMTCTandsupportbeginsatthetimeofthe

marriage.(Theyshouldtestbeforetheygetmarried.)CurrentlythecommunityisalsocarryingoutHIVtesting

beforemarriage.

1.5 Successfactors,gaps,challenges

Successfactors

• ThecloseinterestoftheMekelleRegionalHealthBureauinwhatwashappeningwiththehealthservicesin

Alamata

• TheAlamataTownDistricthealthservicesteam’scommitmenttoaddressingtheproblemofpoorperformance

• Thedecisiontoconductastudytoclearlyunderstandanddefinetheproblemofhomedeliveries

• Theadoption/integrationofculturalpracticesandbeliefsvaluedinhomedeliveries,suchasthecoffee

ceremonyandcelebrationofthebirth

• TheavailabilityofpartnerssuchasIntraHealth,OrganizationofSocialServicesforAIDSandWorldVisionto

supportvariouscomponentsoftheintervention

• WinningoverthechiefTBA

• Understandingtherisksandbenefitsofhomeandhealth-centredelivery

• UsingHIV,analreadyfeltproblem,asanentrypointofemphasisforinstitutionaldeliveries

• IntroductionoftheWomenDevelopmentArmy,withoneofitsrolesbeingtoensureclosefollow-upand

counsellingofmothers

• Districtprovisionthatifawomandiesasaresultofahomedelivery,theTBAandhusbandareheldresponsible

forthatmaternaldeath

• Useofcriticalcommunitystructuressuchaselders,Kebeleleadersandfaith-basedorganisationstoemphasise

themessageofthebenefitsofinstitutionaldeliveries

• ContinuedtrainingofTBAs,mothersandspouses,andleadersonthebenefitsofinstitutionaldeliveriesandthe

risksassociatedwithhomedeliveries


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Gaps

• Shortageoffinancesfortraining,henceheavyrelianceonpartnerssuchasWorldVision.

• Lackofemphasisonthebirthpreparednessplan.Forinstance,mothershavetocallfortheambulanceatthe

onsetoflabour.

• Shortageofdeliveryequipment(e.g.vacuums,Ambubag,deliverysets,Autoclave).

Challenges

• Culturalbeliefs(suchasfearofdeathandfearofannoyingthespiritsinthehome,whichcanresultindeath),

systemsandpractices.Someofthesebeliefshavehadanimpactontheappreciationofimmunisationand

family-planningservices.

• LimitedmaleinvolvementinPMTCTservices.

• UnwillingnessofsomeTBAstostophome-deliveryservicesinthecommunitybecausetheyfearalossof

dignityandtheyfeeltheyareaddressinganeed.‘IwillnotstophelpingmothersdeliverathomebecauseI

haveacalltohumanityforthemotherswhostillwanttodeliverathome,’saidoneTBAinaFocusGroup

Discussion(FGD).


11



Burundiisfacedwithaburdenofchronicmalnutrition.Accordingtothe2010DHSreport,threeoutoffivechildren

under5(58percent)sufferfromstunting;almosthalfofthese(27percent)sufferseverechronicmalnutrition,

while6percentarewasted.TheStateoftheWorld’sChildrenreport2009(UNICEF),statesthat39percentof

childrenunder5areunderweight(moderateandseveremalnutrition,2000–2007).Anaemiaprevalenceinchildren

aged6monthsto59monthsisalsohigh,standingat45percentaccordingtothe2010DHSreport.Poorfeeding

practices,poorhygieneandahighprevalenceofcommunicablediseasescontributetothehighlevelofmalnutrition

withinBurundicommunities.

A2010Knowledge,AttitudeandPracticestudybyUNICEFshowsthatcomplementaryfeedingaftersixmonthsis

insufficientinbothqualityandquantity.Thesamestudyshowedonly32.9percentofchildrenunder2receivethree

mealsaday.Thequalityanddiversityofmealsisnotadequate.Only27.8percentofchildrenfromruralareasaged

6monthsto11monthsreceiveamealcontainingthethreefoodgroups.Thefoodispoorinprotein.Thechildren

eatmainlygrains,tubersandotherroots(45.5percent)andfruitsandvegetables(27.7percent),whilethenumber

whoreceivemeat,eggsormilkproductsislow(7percentformeat,8.8percentforeggsand6percentformilk

products).

AreviewofthesurveyfindingsintheWorldVisionoperationareashowedhighlevelsofchronicmalnutritionamong

childrenunder5(Table1).

Table 1: Malnutrition levels in Burundi area development programmes (ADPs)

ADP Stunting Underweight Wasting Year survey (GAM) conducted

Bugenyuzi 53.0% 37.9% 6.2% July 2009

Gashoho 55.3% 32.4% 4.8% Oct 2010

Gasowre 57.8% 35.4% 5.6% Nov 2010

Gitaba 54.0% 34.9% 7.4% June 2012

Ntunda 63.7% 31.0% 5.7% July 2012


• Rehabilitatemalnourishedchildren

• Topreventnewcasesofmalnourishment

• Tosustainbestpracticesusinglocallyavailablefoodstuffs

2.3Keyactionstaken

Tofulfiltheobjectives,WorldVisionBurundiintroducedtheFoyer d’Apprentissage et de Rehabilation Nutritionelle–

FARN(NutritionEducationandRehabilitationCenters).FARNisalocallearningcentrewheremotherslearnabout

complementaryfeedingpracticesinordertoimprovethewell-beingofchildrenaffectedbymalnutrition.7

2 Focal Nutrition Learning Centres: Using locally available resources to improve child nutrition in Burundi

7 Focal Nutrition Learning Centers: Using Locally Available Resources to Improve Child Nutrition.FieldExperienceinBurundi (August2012)(internaldocument).


12


Thisapproach,endorsedbyBurundi’sMinistryofHealth(MoH),isbeingimplementedinWorldVisionADPs.FARN

usessimilarprinciplestoPositiveDevianceHearth(PD/Hearth)anditspurposeistorehabilitatemalnourished

childrenunder5byusinglocallyavailablefoodproducts,mobilisingthecommunityandinducingbehaviourchange

usingthebehaviourchangecommunicationapproach.

AboutPD/Hearth

PD/Hearthisaninternationallyprovencommunity-basedmodelforrehabilitatingmalnourishedchildrenintheir

ownhomes.Ittargetsmoderatelyandseverelyunderweightchildrenagedbetween6monthsand36months.

WorldVisionfollowedallthestepsforitsFARNimplementation.Communitymobilisationstartedwithengagement

ofthelocalleadersandidentificationofvolunteers.Thecommunitysetitsowncriteriatoselectvolunteers:can

readandwrite;haswell-nourishedchildren;hasacleanhouse,havingatoiletandwithanimalslivinginaseparate

building;isamodelinthecommunity;andcancommittimetofacilitatetheFARNsessionsandworkforthe

communityforfree.Bothsexeswereequallyrepresented.Themainactivitiesofthevolunteerswereasfollows:

• Sensitisethecommunityandconductscreening.

• Maintaintheregisterswithchild’sname,mother’sname,father’sname,child’sage,child’sweightandheightat

admissionandafter12daysand30days,attendanceatFARNsessionsanddate.

• Analysethedataandcapturerecordsofallthechildrenidentifiedasmoderatelymalnourishedfor

rehabilitationinFARN,orreferchildrenwithseveremalnutrition.

• SuggestrecommendedfoodtypesandothercontributionforFARNsessions.

• Followupmothersintheirhomesafterthe12daysofFARNsessions.Thisensuresthatmotherscontinue

practisingthebehaviourstheylearnduringtheFARNsessions,suchasdiversifyingthefoodandwashingtheir

handsbeforepreparingthefoodandfeeding.Thefactthattheyarenothavingreadmissionsisanindicatorthat

themothersarepractisingwhattheylearn.

• IdentifyandpreparethelocationforPD/Hearthsessions.ThehomewheretheHearthwasestablishedhadto

belongtoaPositiveDeviantfamily–afamilywithawell-nourishedchild.Italsoneededtobehygienic,spacious

andeasilyaccessiblebymostmembersofthecommunity.

• Mobilisethemotherstocontributewater,firewoodandfoodsuchassweetpotatoes,cassava,bananas,beans

andvegetables.Insomesessionsmotherscontributed100Burundifrancseach,whichwasusedtobuycooking

oil,smallfishandgroundnuts.WorldVisionprovidedcookingutensils,matsandthetarpaulinforshade.

• Throughhill8leadership,sensitisethecommunitiesonGrowthMonitoringPromotion(GMP)andremind

motherstotaketheirchildrenforGMPactivities.

Foreachhill,positivedevianceinquiry(PDI)wasconductedonce.Sincethereisonlyonehill-levelleadershipand

volunteergroupconductingthesessionateachhill,therewasonlyoneFARNsessionconductedinonehousehold.

Duringthetrainingoffacilitators,afoodcompositiontablewasusedtocalculatethenutritionalrequirements,

whichwerethenconvertedtothelocalunits.However,fillingtheironrequirementfromlocallyavailablefoods

duringthemenu-planningmeetingwasnotpossible.Table2showsachild’ssamplemenupreparedduringtraining.

Itwasnotpossibleforallvolunteerstoconductvisitseveryonetotwodays.Theydid,however,managetoconduct

weeklyvisits,dependingontheneed.

8AhillisalocaladministrativeunitatthevillagelevelinBurundi.


13


13

Table 2: Sample menu prepared during a Hearth session

Food/meal Weight in grams Home measurement

1. Lengalenga 80 gms Handful

2. Cassava (pate) 25 gms 2 Tablespoonful

3. Haricot beans 50 gms Handful

4. Oil 10 gms 2 Tablespoonful

5. Salt 2 gms 2 Pinches

6. Groundnut 50 gms Handful

Snack

Banana 48 gms 1 small piece

2.4Achievements

Sessionsheldandvolunteersmobilised

Twohundredandfivesessionsweresuccessfullyconductedin48hills(seeTable3).Atotalof510volunteerswere

trainedtofacilitatetheFARNsessions.

Table 3: Number of health sessions conducted and volunteers trained, by ADP

ADP Hills # of sessions Children # of children admitted rehabilitated

Rugazi

Gashoho

Gasorwe

Cankuzo

Rutegama

Mushikamo

Total

12

6

11

8

5

6

48

3

2 (one session per hill)

205

24 (2 sessions per hill)

26

7

19

16

12

32

35

7

6

301

82

155

236

22

26

2,431

177

104

308

434

75

78

219

67

131

162

16

19

2,157

152

82

218

549

69

54

433 419

16 (two sessions per hill)

2010 2011 2012 2010 2011 2012 2010 2011 2012


14


ChildrencoveredinFARNsessions

Out of the 10,568 children screened, 2,052 childrenwere found to be underweight andmalnourished andwere

admittedtoWVFARNsessions inFY2011and2012.TheaveragenumberofchildrenperFARNsessionwas11.

Amongtheparticipants,59percentwerefemaleand41percentmalechildrenunder5(Figure3).

Figure 3:TotalnumberofchildreninWVFARNprogramin2011and2012(N=2,028)

1,188(59%)

840(41%)

male

female

ThemajorityofchildrenwhoparticipatedintheHearthsessionswereaged12monthsto23months,followedby

thoseaged24monthsto35months.Nearlyhalf(43.5percent)ofthetotalnumberofchildrenwhoparticipatedinthe

FARNsessionswereundertheageof24months(Figure4).Thisprovidesahugewindowofopportunitytoprevent

theimpactofchronicmalnutritionanditsirreversibleconsequences.

Figure 4: Age distribution of children admitted to FARN 2011 & 2012 (n=2,052)

24–35 months

36–48 months

49–60 months

>60 months

700

600

500

400

300

200

100

0

12–23 months

6–11 months

0-11

mon

ths

12-2

3 mon

ths

24-3

6 mon

ths

36-4

8 mon

ths

49-6

0 mon

ths

>60 m

onth

s

250

643

503

326

252

78

Nu

mb

er

Age


15


Rehabilitationoutcome

Recovery rate at 12 days and 30 days of FARN sessions:Among2,052childrenintheprogramme,

2,022completedthe12-daysessions.Ofthose,1,526(76percent)gainedtheweightneededfortransfertothe

homevisit,witha1percentdefaulterrate(Figure5).Duringthe2011implementationperiod,manyoftheFARN

sessionsdidnotmeasuretheweightofchildrenat30days.Thisisbecausethevolunteerswerenottrainedtotrack

theweightofchildrenoncetheyweredischargedfromtheprogramme.However,in2012thevolunteersweighed

atotalof807childrenandcomparedtheirweightwiththeiradmissionweight.Overall,631(78percent)ofthe

childrenhadgainedover400gatonemonth,meetingtheprogrammegraduationcriteria.At30days,theproportion

ofchildrendefaultingfromtheprogrammehadincreasedto14percent(Figures5and6).

Figure 5:FARNoutcomeindicatorsat12days(N=2,022) Figure 6:FARNoutcomeat30days(N=807)

Death

Defaulter

No weight change

Weight loss

Weight gain 0-200g

Weight gain over 200g

Death

Defaulter

No weight change

Weight loss

Weight gain 0-200g

Weight gain over 200g

Theoutcomeoftheintegratedhealthserviceswasthatchildrenreceivedbenefitssuchasdeworming,vitaminAand

thelinkagetohealthservices.TheADPmanageratGashohostatedthatchildrenintheirADPwereenjoyinggood

health.Thelocalgovernmentalsoextendeditsrequesttoexpandtheservice.

Average weight gain:Bytheendofthe12days,theaverageweightgainoftheprogrammewas373g.Bytheend

ofthe30daystheaverageweightgainwas689g.ThedistributionoftheweightgainissummarisedinFigure7below.

Figure 7: Distribution of weight gain by the of 30 days (n=677)

250

200

150

100

50

0

Number of children

100 - 300 400 - 500 600 - 700 800 - 900 1kg & over

Weight in gms

47

237

180

86

127

Nu

mb

er

of

chil

dre

n


16


ImpactofFARNonoverallmalnutritioninthecommunity

GrowthanalysisusingtheWorldHealthOrganization(WHO)standard:UsingStandardizedMonitoringand

AssessmentforReliefTransition(SMART)software,workersconductedanalysistoassessthelevelofmalnutrition

atadmission,at12daysandafter30daysofinvolvementintheFARNprogramme.Improvementsinchildgrowth

areshowninTable4.Theresultwasthatthelevelofsevereunderweighthasdeclinedfrom49.2percentto

17.2percent(WAZscore<−3SD,seeTable4).Thereislittlechangeinmoderatemalnutrition,whichcouldbethe

resultofmovementofmanyofthechildrenfromseveremalnutrition.

Table 4: Levels of malnutrition after FARN sessions (N=677)

No Malnutrition

At Risk of malnutrition (WAZ < 0 & > -1 SD)

Mild Malnutrition (WAZ < -1 & > -2 SD)

Moderate malnutrition (WAZ < -2 & > -3 SD)

Severe Malnutrition (WAZ < -3 SD)

Admission 0.0% 4.9% 16.2% 29.8% 49.2%

12 days 1.5% 6.7% 20.2% 31.9% 39.7%

30 days 2.3% 17.4% 37.0% 26.1% 17.2%

Case study 1: World Vision field experience and its contribution to the development of national level FARN guidelines

TheFARNapproachisamongthecommunity-basednutritioncomponentsofthenationalprotocolof

managementofacutemalnutritionwhichwasvalidatedinApril2010.Aftertheprotocolvalidation,the

nutritiondepartmentofthegovernmentofBurundianditspartnersembarkedonaprocesstodevelop

FARNnationalguidelines.WVBurundiwasamongthepartnersthatcontributedtothedevelopment

oftheseguidelines.AmeetingofvariouspartnerswasheldintheMoHin2011topresenttheFARN

approachestheywereusing.WorldVisionparticipatedinthismeetingandsharedtheRugaziFARN

experience.InAugust2011,attherequestofMoH,WorldVisionsharedtheguidelinesitisusingtorollout

FARNinitsoperationareas.Afive-dayworkshopwasorganisedinGitegaProvinceinDecember2011to

designthefirstdraftofFARNguidelinesforBurundi.

WVBurundi’sHealth,NutritionandHIVprogrammeofficerwasonthesix-membercommitteetasked

tofinalisethedraftguidelines.TheothercommitteememberswerefromInternationalMedicalCorps,

WorldFoodProgramme(WFP),UNICEFandthegovernment.BasedontherecommendationoftheGitega

workshop,thecommitteeconductedafieldvisittoFARNsites,includingWorldVision’s,andreviewedthe

implementationfeasibilityanddrewlessonsbeforefinalisingtheFARNguidelines.

WorldVisionwasinvitedtoparticipateinthefinalisationandadoptionoftheFARNnationalguidelines

workshopheldonApril26and27,2012,inGitegaProvince.Duringthismeeting,theWorldVision

NutritionistspecialistAristideMadagashamadeapresentationontheWorldVisionimplementation

strategy.ThedecisiontorequestWorldVisiontomakeapresentationfollowedajointUNICEF-WFPfield

visittoRutegama,RugaziandGasorweADPs,April24and25,2012.


17


Followingthismeeting,atechnicalcommitteewassetuptofinalisetheFARNnationalguidelinesdocument.

Again,WorldVisionwasselectedtobeapartofthiscommittee,whichalsohadrepresentativesfrom

UNICEF,WFPandtheMinistryofHealthnutritiondepartment.WorldVision’smajorinputwasrequired

forimplementationmodalities,especiallybudgetingforFARNsessionactivities,specifyingkeyinputsthat

needtobeplanned.

Duringthefirstweekofthenationalforumfornutritionandfoodsecurity(December2011)WFPand

UNICEFaskedWorldVisiontomakeapresentationonPD/Hearthandtheimplementationprocess.It

wasthefirsttimethegovernmentorganisedaforumtodiscussnutritionandfoodsecurityissueswithall

thepartnersinvolvedinnutritionandfoodsecurityactivities.Theforumalsoattractedparticipationfrom

regionalleadersofUNagencies.

2.5Successfactors,gaps,challenges

Successfactors

• CommunityparticipationandactiveinvolvementisthebackboneoftheFARNprogramme–akeysuccess

factor.Communityinvolvementcanincludeprovidingleadership,sensitisation,identificationandsupporttothe

volunteers,identifyinghouseholdstohosttheFARNsessionsandcontributingthefoodandequipmentneeded

fortheFARNsessions.ThehealthpromotiontechnicianforKaruzidescribesthecommunityashighlywillingto

participateandcontributetotheFARNsessions.

• TheexperienceatGashohoADPillustratesthecommunitycontribution.TheFARNsessionsareorganised

withvolunteersselectedfromthecommunitywiththeleadershipofthehillleaders.Thegrouphasaboutequal

representationofmenandwomen.Thishashelpedtoinvolvemeninthepromotionoftheprogramme.

Currently115trainedvolunteercommunityworkersareactivelyinvolved,witharetentionrateof95.8per

cent.WorldVisionprovidesaraincoatandatransportallowancewhenthevolunteerstravelfortraining,but

thereisnootherincentive.

• Inoneofthecommunitymeetingsavolunteersaid,‘Weareworkingforourownchildreninthecommunity

andthechildrenofBurundi.Weworktoprotectthemfromillnesses;wearehappywiththeworkandwill

continueworkinguntiltherearenomalnourishedchildreninthecommunity.Therelationshipwiththefamilyis

goodandthatismotivationforus.’

• Initiallymenthoughtthatifthemotherstookfoodfromtheirhomestothesessions,thenthechildrenathome

wouldnothaveenoughtoeat.Fathersalsodidnotunderstandhowmotherscouldspend12daysattheHearth

sessions.Volunteersandcommunityleadershelddiscussionswiththemenandrealisedthatoneofthemajor

concernswasthetimethemothersspentattheHearthsessions.Theyagreedtospendamaximumoftwo

hoursatanyHearthsession.

• BeforestartingPD/Hearth,WorldVisionenteredaMemorandumofUnderstandingwiththeMoHto

implementFARNinthecommunity.Astheimplementationstarted,WorldVisionfieldteamsmetwiththe

districtandprovincialofficestodiscusstheimplementationprocess.Table5describeshowpartnerswere

involvedduringtheFARNimplementation.


18


Table 5:RoleofPartners’inFARNimplementation

Partners Roleofpartners

HC/healthpromotiontechnicians • Followupactivitiesandmonitoringofrehabilitatedchildren.• Trainingvolunteers.• Conductscreeningandgrowthmonitoring,de-wormingandvitaminA

supplementation.• Examinationofchildrenwithmalnutritionandtreatthem,selectcases

andtreatforillnessesandrefercaseswithmedicalcomplicationtostabilisationcentre.

• Training,sensitisationofmothersandsupervisionofcommunityhealthworkersandvolunteers’activitiesinthecommunity.

TheDistrictandProvinces • Supervisionandextensionplanstootherareasbuttheseareatearlyphase.

• Ownershipoftheapproachandsupport.

CommunityandHillleaders • Sensitisationandcommunitymobilisation.• Supporttothevolunteerstoeffectivelyprovidetheirservices.• Contributefood,referchildrenforscreening.

WorldVision • FacilitateMoUwithpartnersandallocatethefund.• Transportfeeduringtraining,conductjointsupervisionandreview

meeting.• Assignfocalperson.• ImplementintegratedprojectsthatsupportFARNactivities.• Shareditsexperienceandprovidedafield-basedlearningtoinformthe

nationalFARNguidelinedevelopment(refertothecasestudy1).

Challenges

Duringakey-informantinterviewAlexisKabona,aPathfinderemployeewhoworksonhealthandnutrition

programmesinthedistrict,identifiedthefollowingchallengestoFARNimplementation:over-population,limited

landsizeandlowfamily-planningpractice.

Othermajorchallengesemergedfromkey-informantinterviewsandfocusgroupdiscussionswithWorldVision

staff,healthworkers,provincialanddistrictofficials,volunteers,andthebeneficiaries.Theyaresummarisedas

follows:

• lackofgrowthmonitoringandpromotioninthecommunity

• lackofinstitutionalisationoftheFARNactivitiesaspartoftheoutreachactivities;onlychildren

whocometothecurativeservicesarecurrentlygettinggrowthmonitoring

• limitedfield-levelstaffandlackoftransportationtoconducton-sitesupportandensurequalityof

theFARNsessionsanddatamanagement

• foodshortageinsomeseasonsandlackoforpoorqualityofoil

• mothersbringingsimilartypesoffood

• reluctanceofsomecommunitymembers,forreligiousreasons,toallowweighingofchildren

• highpopulationpressure

• women’slackofdecision-makingpoweronresources.


19



Bondoisoneof37districtsofNyanzaProvinceinKenya,withatotalareaof1,084km2,ofwhich500km2isLake

Victoria,thesecondlargestfreshwaterlakeintheworld.ItbordersBusiaDistricttothewest,SiayaDistricttothe

north,SubaDistricttothesouthandRariedaDistricttotheeast.Therearesixinhabitedislandsand66beaches.

BondoDistricthasoneofthehighestinfantmortalityratesinKenya,at110infantsper1,000livebirths,whilethe

under-5mortalityrateis208per1,000livebirths.Maternalmortalitystandsat620per100,000livebirths,well

abovethenationalfigureof488per100,000recordedbytheKenyaDemographicandHealthSurvey2008–2009.

Thedistricthas34healthfacilities,comprising1hospital,7healthcentresand26dispensaries.Thegovernment

ownsthehospital,6healthcentresand18dispensaries;theothersareownedbyprivatesector/faithbased

organisations.

ForthreeorfourconsecutiveyearstheindicatorsforessentialMCHserviceswerenotgood,withskilledbirth

attendancestandingat17percent,fullimmunisationinthe50s,fourthANCvisitandfamilyplanning(FP)low.The

AnnualOperatingPlan6(AoP)indicatorsbecameadecisivepointinMay2011.Immunisationcoveragewasbelow

60percent,thoughthenationaltargetis80percent;FPuptakewasaround46percent;andANCvisitswerealso

low(BondoMoH).Therewerecasesofdropoutforservices,meaningthatthosewhoinitiallyreportedforservices

didnotreturn.Therewasnounderstandingofwhyclientsweredroppingout.Itwasequallyconfusingthat,withthe

highnumbersofCHWs,thedistrictcouldnotmeetitstargets.Thisobservationindicatedaneedforanevidence

basefordecision-making.Thedistrictimplementedthecommunityhealthstrategyin2010toensurecommunityuse

ofthehealthfacilities.However,realignmentofcommunityunitstonewpolicystartedinMarch2011.

Themissionofcommunityhealthservicesisforthecommunitytobecomethemeansofsocialtransformationfor

developmentatthecommunitylevelbyestablishingequitable,effectiveandefficientcommunityhealthservicesin

communityunitsalloverKenya.

ThekeyfocusforBondoDistrictwastorevamptheCHWstructureandestablishafocusondefaultertracing

forimmunisationandANC.Theydidthisbyintroducinganexitdeskatallhealthcentres,staffedbyCHWsona

rotationalbasis;theyalsointroducedanappointmentsdiaryinwhichtheycouldtrackcontinuingusersofhealth

servicesandmapthedefaulters.

ThedistrictdeterminedtochangeitsseeminglygloomyscenariowithAoP7(2011/2012).‘Wethoughtwecould

accelerateCUcoverage,’saidJoelMilambo,communityhealthstrategyfocalperson,chargedwithensuringthe

rolloutofthenewcommunityhealthstrategy.TheDistrictHealthManagementTeam(DHMT)wantedasystem

thatwouldbeabletoaccountfordefaulters,especiallypregnantwomenandchildrenagedunder1year,besides

accountingforotherhealthservices.


StrengtheningofdefaultertracingforessentialMCHservicesbyintroducinganexitdeskandanappointmentsdiary

inallhealthfacilitieswasguidedbythreeobjectives:

3 Defaulter tracing: Using defaulter tracing for essential maternal and child health (MCH) services in Bondo District, Kenya


20


• toimprovecommunityandfacilitylinkage

• toestablishanevidencebasetoinformMCHplanninginthehealthfacilities

• toimproveuptakeofANCandimmunisationservicesformothersandchildrenunder1year.

3.3Keyactionstaken

Thedistricttookthefollowingactionsasawayofstrengtheningthecommunityhealthservicesstrategy:

• revampedtheoldCHWstructure,whichhadoneCHWcovering20HHs,andfollowedthenewpolicy

guidelines(2010)thatprovideforoneCHWper100HHs;thisnewstructureinformedtherecruitmentof

CHWs

• recruitedCHWsandCHCmembersasperthenewpolicyguidelines

• trainedtheCHWs

• conductedhouseholdmappingandregistration,whichisnowdoneeverysixmonths

• institutedperformance-basedassessmentforCHWs,identifyingspecifictargetstomeet

• hiredanadditional10communityhealthextensionworkers(CHEWs)tosupervisetheCHWstructure

• engagedkeystakeholders,includingprovincialadministratorssuchaschief,villageheads,assistantchief

• disseminatedtherevisedMoHreportingtools

• strengthenedcommunitydialoguedays(discussinghealthissueswiththecommunity,informedbythe

indicatorsonthechalkboard)andactiondays(executinganactionplanagreedonduringthedialoguedays)on

amonthlybasis

• introducedtheexitdeskstaffedbyCHWsonrotationalbasis

• introducedanappointmentsdiaryasawayoftrackingdefaultersattheexitdesk.

Engagingcommunityhealthworkers

Recruitment

FromMarchtoMay2011thedistrictplacedadvertisementsinvarioussublocations,callingforCHWs.Thevillage

headsthenidentifiedCHWstoinvolveintheprocess.Theseweresenttothechief’sbaraza(communitymeeting),

wheretheywerevettedandrecruited,followinggovernmentguidelines.RecruitmenttookplacebetweenMayand

July2011.

Training

Afterrecruitment,CHWsreceivedorientationandtrainingonthecommunityhealthservicesstrategyintheir

respectivesublocations.ThelastmajorCHWtrainingthatfocusedoncommunitystrategywasconductedin

October2011.Duetolimitedresources,thistrainingranfor10daysinsteadofthestipulatedsixweeks.The10-day

trainingcoveredcommunitycasemanagement;communityHMIS;TB/HIV;diseasepreventionandcontrol;water,

sanitationandhygiene(WASH);andcommunitymaternalandnewbornhealth.Itisimportanttonotethatall363

CHWshavereceivedtraining.

Job aids

Followingtraining,CHWsreceivedvarioustoolstodotheirwork,includingthehouseholdregister(MoH513),the

CHWservicedeliverylogbook(MoH514),whichisfilledinonamonthlybasistogeneratedata,andachalkboard

forthehealthfacilities.Thechalkboardprovidesaglimpseofthehealthstatusofanygivenfacility.CHWsalso

receivedthestandardMoHcommunityreferralforms.


21


Besidesthetools,CHWsreceivedotherjobaidssuchasbadges,bagsandInformation,Educationand

Communication(IEC)materialsspecificallyfocusingonMCH.

Household mapping and registration

Followingthetraining,thefirstCHWactivitywashouseholdmappingandregistration.Dependingonthenumberof

householdsaCHWhadtocover,theexercisetookfromfivedays(forthosewithlessthan100HHs)totwoweeks

(forCHWswithmorethan200HHs).ThemappingwasdonewithakeyfocusofestablishinganumberofMCH-

relatedindicators,includingthenumberofpregnantwomen,numberofchildrenunder1year,numberofchildren

exclusivelybreastfed,numberofwomenofreproductiveage.

Target setting

Afterthemappingexercise,CHWssettargetstoachieveonamonthlybasis.Theideabehindthisexercisewasto

ensurethatastheCHWsdidtheirwork,theyhadatruepictureoftheircatchmentareasandwouldknowwhat

particularhouseholdstoprioritiseforvisits.

Continuing training

TheCHWsreceivedcontinuoustrainingfromvariouspartners.Someofthetrainingprovidedwasonmother-child

integratedprogramming,reportingtoolsandinfectionpreventionandcontrol.

Staffing the exit desk

Oneveryworkingday(MondaytoFriday),anassignedCHWwillbeatthehealthfacilityfrom8a.m.to4p.m.and

willgeneratealistofpatientswhoareexpectedtocomeforservicesandthosewhohavedefaulted.Thisprocessis

facilitatedthroughanappointmentsdiary.

The appointments diary

Theappointmentsdiaryisacriticaltooldesignedtotrackcontinuingserviceusers.Theserviceusersareidentified

fromtheANCandimmunisationregisters.Itwasnoted,however,fromthevisitedsitesthatuseofthistoolisnot

standardised.TheentriesvarywiththeCHWs.Inonecase,forexample,diaryentriesreflectedacompiledlistof

defaultersattheendoftheday;othershadsimplymarkedparticipants,providingnosummaries,andrecordsfor

somemonthsweremissing.Inanotherdiary,bothnewandcontinuingclientswereregistered.

Astheappointmentsdiarywasdistributedtothehealthfacilities,nospecifictrainingonitsusewasprovided.This

lefttheCHWswithoutadequatesupportforusingthetool.

Remuneration

Communityhealthworkersarevolunteers.BondoDistrict,however,isfortunatetohaveapartnerMaternaland

ChildHealthIntegratedProgrammewhohascommittedtoprovideastipendof2,000Kenyanshillings(Kshs–

approximatelyUS$25)tothe363CHWsinthearea.ThisstipendisbasedontheamountstipulatedinKenya’s

March2011communitystrategypolicyguidelines.However,thestipendisnotguaranteed.Aworkermustscoreat

leastfiveoutofsevenpointsinamonthinordertoreceivethismoney.Theareasassessedforperformanceare:


22


• referralofatleasttwopregnantwomen

• referralofachildforimmunisation

• participationindialogueandactiondays

• householdvisits

• completeandtimelysubmissionofreports

• communitymobilisation

• defaultertracing.

Figure 8: Defaultertracingflowchart

Extract list ofdefaulters from

the diary

Make phonecalls to CHWs

concerned

CHW visit thehome of a defaulter

CHWs defineswho is a defaulter

CHW soughtreason for defaulting

defaultercentered reason

YES

Refer to healthfacility for

service

Seek assistancefrom fellowCHW/CHC/

CHEW/HF/PA

Follow up toconfirm referral

Health facilityvisit to checkreferral file

Home visit to check health

card

NO

CHW negotiates

with defaulter

Otherreasons

Message directed to the party

concern


23


3.4Achievements

StrengtheningthedefaultertracingforessentialMCHserviceswiththeintroductionofanappointmentsdiarywas

thekeyactivityinBondoDistrict,guidedbythreeobjectives.Thissectionspellsouttheachievementsthedistrict

hasregisteredfromJune2011toJuly2012.

Theappointmentsdiary

Theappointmentsdiarytofacilitatedefaultertracingwassuccessfullyintroducedinallthethreedivisions,enabling

BondoDistricttotracktargetsandgeneratedatathatinformtheirplanning.Oneoftheindicatorsofinterestfor

managementisthenumberofpregnantwomenwhodonotattendatleastfourANCvisitsasshowninFigure9.The

DHMTindicatedthattrackingsuchinformationenablesthemtosystematicallyplanforimprovementastheyare

nowabletogenerateanevidencebase.

Figure 9: ANC non-attendance in Bondo District

700

600

500

400

300

200

100

0

JUL-

13

AU

G

SEPT

OC

T

NO

V

DEC JAN

FEB

MA

RC

H

APR

IL

MAY

JUN

-13

Pregnant women who did not attend at least4 ANC Visits

No.

of m

othe

rs

Months

Defaultertracing

Althoughitwasnotpossibletoestablishalldefaultersidentifiedacrossthedifferentservices,therewererecords

forimmunisation(recordingbothdefaultersthatwereidentifiedandthosewhoweretracedandsubsequentlytook

upservices).Anotherproxyindicatorfordefaultertracingwasthenumberofpregnantwomanreferred,asshown

inFigures10,11and12.


24


Figure 10:ImmunisationdefaultersidentifiedinBondoDistrictFigure 11: Immunisation defaulters traced

900800700600500400300200100

0

No

. of

mo

the

rs

Months

No

. of

mo

the

rs

Months

Immunisationdefaulters traced

JUL-

11

AU

G

SEPT

OC

T

NO

V

DEC JAN

FEB

MA

RC

H

APR

IL

MAY

JUN

-12

1,200

1,000

800

600

400

200

0

JUL-

11

AU

G

SEPT

OC

T

NO

V

DEC JAN

FEB

MA

RC

H

APR

IL

MAY

JUN

-12

Immunisationdefaulters

Figure 12: Pregnant women referred to the health facilities in Bondo District

sre

hto

m fo .

oN Pregnant women

referred

Months

700

600

500

400

300

200

100

0

JUL-

11

AU

G

SEPT

OC

T

NO

V

DEC JAN

FEB

MA

RC

H

APR

IL

MAY

JUN

-12

Strengtheninghealthstructures

Thedistrictestablished26communityunits(100percent)coverage,recruited52CHEWsandidentified260

communitymembers.

TherewasnotableimprovementinthelevelofcommitmentofCHWs.Respondentsrevealedthatwiththeold

policy,inwhichoneCHWwasassigned20HHs,CHWsweretoomany,andtherewasnodemonstrableimpactof

theirwork.

Increaseinuptakeofmaternalchildhealthservices

TherewasanincreaseinuptakeofMCHservices.AttendanceatthefourthANCappointmentincreasedby

17percent(from4,995clientsinAoP6[2010/11]to5,868clientsinAoP7[2011/12]),skilledbirthattendanceby

28percent(2,444mothersinAoP6comparedwith2850inAoP7),familyplanningby6percent(20,335clients

inAoP6comparedwith21,478inAoP7)andPMTCTby9percent(1,122mothersinAoP6comparedwith1,226

mothersinAoP7).(SeeFigure13.)UptakeofimmunisationservicesforBacillus Calmette–Guérin (BCG)increasedby

67percent(5,484childrenreceivedtheBCGantigeninAoP7comparedto3,277thepreviousyear).

(Seefigure14.)


25


Figure 13: Uptake of key maternal health services in Bondo District

25,000

20,000

15,000

10,000

5,000

0

SBA PMTCT

AoP6

AoP7FAMILY

PLANNINGANTENATALCARE

Maternal health services received

No.

of w

omen

Figure 14: Uptake of immunisation services in Bondo District

Immunisation antigens received

No.

of c

hild

ren

6,000

4,000

2,000

0

AoP6

AoP7

BCG MEASLES FULLYIMMUNISED

ORAL POLIOVACCINE

Case study 2: ANC and Immunisation support groupsat Got Matar Health Centre

TheprocessofdefaultertracingforessentialMCHservicesledtosomeotherinnovations.GotMatarHealthCentre,acentrethatwaselevatedfromadispensarylevelatthebeginningofthisyear,introducedANC-and-immunisationsupportgroups.

Accordingtothenurseinchargeofthisfacility,thisefforthasseenmoremotherscompletethefourANCvisitsandallmothersinthegroupdeliveringatthefacility.Theotherbenefitisthatmothersinthegroupshavebeenabletodoexclusivebreastfeeding.Thegroupsrunontheirown.Thefacilitybecomesinvolvedonlytoprovidetechnicalsupportwhenmothersaregrapplingwithpracticalquestions.Mothersmeetonamonthlybasis,andtheyhaveintroduced‘Merry-go-rounds’,whereeachmothercontributesKshs30.Themoneyispooledandgiventoonemother.Mothersareencouragedtousethismoneyfortheirbirthplans.Thefacilityalsoensuresthatmothers’ANCvisitsarescheduledonthesamedayastheirsupportgroupmeetings.

Thefacilityhasnotgonewithoutchallenges:‘Thedispensarywasgazettedasahealthcentre,butintermsofstaffingwehaveremainedwhereweare,’saidthenurseincharge.‘Theworkloadistoomuch.Wearemulti-taskingtomanage.’


26



Successfactors

• Commitmentofapartnertoprovidetheperformance-basedmonetaryincentive.ThegovernmentofKenya

stipulatesamonthlystipendforCHWsofKshs2,000(approximatelyUS$25).

• IntegrationoftheCHWsintothemainstreamhealth-facilityserviceprovision,whichwonthemmorerespect

fromthecommunities

Gaps

• Alotisbeingdoneontheground,butthereisnosystematicwayofcapturingthedefaultertracingactivities

thathavereportedlybeenspreadacrossallthe26communityunits.The363CHWsaredoingalotofwork

thatmaygounrecognisedduetolackofevidence.

• Therehasnotbeenanydetailedtrainingondefaultertracingforallcadresofhealthworkers.Thismayaffect

thequalityofservice.

Challenges

• Somereligiouspractices(e.g.thoseofNomiyachurchandtheRohomovement,whichkeepchildrenindoors

forthreemonthsbefore‘exposingthem’tothesurroundingenvironment)resultsinmembersofsuchsects

defaultingfromkeyservices.

• Themigrationpatternoftheboarderpopulationaffectstheoutcomeoftheservices.Itiseasytolosefollow-

upaspopulationsarenotinonespace.

• Sustainabilityoftheprogrammebeyondacommittedpartnerisquestionable.

• Thequalityofthedataisachallenge.Anumberofindicatorsarenotconsistentlyrecorded,whichmightlead

tounder-orover-reportingofresults.

• WhilstthetargetforCHWsisform-fourcompletion,thestipend,whichisamajormotivation,isnotattractive

enoughtothetargetrecruits.InaninterviewwithaCHEW,herevealedthatmostoftherecruitsarebelow

formfour.Peoplebelowthislevelfinditverydifficulttoconceptualisetheissues.TheCHEWshavetospend

moretimeaddressinggaps.

Service-specific challenges

• LongwaitingtimefortheANCprofile,insomecasesuptosevenhours,especiallyforthefirstvisit.This

mayaffectsubsequentvisits.Partoftheexplanationforthisisthatgovernmentpolicyguidelinesprovidefor

detailedengagementwithamotheronthefirstvisit.OneDHMTmembersaidtheyneedtotreatclientsasif

theywillnotseethemagain.

• FearoftakingtheHIVtest.

• Painofthevaccinationshot.

• PerceptionthatHCsaresimplymakingprofitofftheuserfees.

• Perceptionthatmalehealthworkerswillmakesexualadvancestothewomen.


27


Timeandcostinganalysis

Time

ThemajorityofCHWswhoparticipatedintheFGDsindicatedthatittakesanaverageofone-and-a-halftotwo

hourstoconvinceadefaultertogobacktothehealthfacilityforservices.Somecasescantakeuptotwodays.This

isdependentonaclient’srelationshipwiththeCHW,client’sperceptionofqualityofservicesatthehealthfacility,

thelevelofsupportfromthespouse,conflictinginterests(e.g.whethertoattendtootherpressingneeds)and

distancetobecovered.Itispossiblethatsuchextrahoursspentdoingprogrammeworkmayfailtobecaptured

whenplanningCHWsstaffhoursandinturnbecomeasourceofdemotivation.

Costing analysis

Itwasnotpossibletoascertaintheactualcostofwhatittakestorunadefaultertraining.However,thefollowing

elementsareofsignificantimportance:

Training:Thisisakeycomponentandamajorexpenditureareaofadefaultertracingprogramme.Itisimperative

thatalltrainingcostinputsbecapturedtopaintaclearpictureofwhatittakestoinitiateandmaintainadefaulter

tracingprogramme.DemandforadditionaltrainingsessionswasexpressedbyCHWsinmosttheFGDs.

Reporting tools and job aids:Anothermajorareaofconsumableexpenditureworthcostingisthe

communityhealthinformationsystem,whichincludesdevelopment,productionanddistributionofthefollowing

reportingtools:householdregister(MoH513),servicedeliverynotebook(MoH514),CHEWssummaryreport

(MoH515),CHWstandardisedreferralform,motherandchildhealthbooklet(MoH216),childcliniccard,

immunisationregister(MoH510),ANCregister(MoH45)andchalkboard(MoH516).Currentlytheseareprocured

inNairobianddistributedtothefield.OccasionalshortageswerereportedbytheDistrictMedicalOfficerof

Health(DMOH);insuchcases,theformsarephotocopiedlocally.Alongwiththesearejobaids/toolssuchasIEC

materials,bags,T-shirtsandbadgeswhichareissuedtoCHWstofacilitatetheirwork.

Airtime: CHWuseofthehealthfacility’smobilephonetotracedefaulterswasreported.Thishasacost

implicationinthepurchaseofairtimetomakecalls.

CHWcallstoescortclientstothehospitalwerereportedinoneFGD.Itisimportanttocapturethesegestures

astheyhaveabearingonthepressureofworkontheCHWandtheCHWmayalsobespendinghisorherown

moneytotransportthedefaulter.

CHEWs’ direct support to the CHWs:Thisisanotherareathatrequirescostingtomonetisetheinputs.

Theseincludesupportivesupervision,updates,on-jobtrainingandfeedbacksessions.

Transport facilitation for CHWs e.g. bicycles: CHWsreceivebicyclestofacilitatetheirhomevisitsas

wellasmotivatethem.However,manyoftheCHWshavenotyetreceivedbicycles.


28



TheUSAIDHealthCareImprovement(HCI)projectdevelopedtheCommunityHealthWorkerAssessmentand

ImprovementMatrix(CHWAIM)toolkittohelporganisationsassessCHWprogrammefunctionalityandimprove

programmeperformance.Builtaroundacoreof15componentsdeemedessentialforeffectiveprogrammes,

CHWAIMincludesaguidedself-assessmentandperformance-improvementprocesstohelporganisationsidentify

programmestrengthsandaddressgaps.Throughdiscussionandreviewofcurrentpractices,theprocessassists

understandingofbestpractices,buildsconsensusaboutandcommitmenttochangeandprovidesguidancefor

improvingfunctionality.

CHWAIMassiststheassessment,improvementandplanningofCHWprogrammesbydeepeningunderstanding

oftheelementsofsuccessfulprogrammesandtheuseofbestpracticesasanevidence-basedapproachto

improvement.Theassessmentisbasedonalignmentwithnationalguidelines.

WorldVisionInternationalmadeadecisiontousetheCHWAIMin2011.InEastAfrica,healthsystems

strengtheningisoneofthehealthandnutritionstrategicapproachesfocusingonequippingCHWstofacilitate

implementationofcorehealthandnutritioninterventions.Thetoolwasthereforeembracedtoachievethefocus

onHSS.


TheCHWAIMtoolhasclearlyspeltoutobjectivesforanyfunctionalityassessment.Theseobjectivesprovidethe

basisforstrengtheningacommunityhealthsystem.Thethreeobjectivesare:

• toassessfunctionalityandguideimprovementinprogrammesdeliveringservicesatthecommunitylevel

• toprovideactionplanningandbestpracticestoassistinstrengtheningprogrammes

• tomapfunctionalCHWprogrammesandgapsincoverage.

4.3Keyactionstaken

• ReviewofcountryCHWpolicy.

• AdaptationofthevalidationtoolaspertheCHWpolicy.

• Athree-daystakeholdersworkshopforthescoringoftheprogrammaticcomponents.Thisactivity

includesreviewingthetoolandprovidingaclearexplanationofwhatisentailed.

• Avalidationexercise–interviewingCHWstovalidatetheinformationprovidedinthestakeholdersworkshop

• Areviewofthescoresnormallyprovidedintheinitialmeetingwithstakeholders.

• Developmentofanimprovementmatrixclearlyspellingoutwhatactionsneedtobedone,andwhodoeswhat

Variousstakeholdersusuallytakeupdifferentaspectsforimprovement.

Processofrollingoutthefunctionalityassessments

Opportunitiestoadaptthetoolcamewithgrantopportunitiesthatwereintendedtoworkthroughtheexisting

communityhealthstructures,specificallytheEastAfricaMaternal,NewbornandChildHealth(EAMNeCH);Access

toInfantandMaternalHealth(AIM-Health);SustainableTransformationinAgricultureandNutrition(SUSTAIN)in

Tanzania;andActforLifesavingActionstoReachMothers(ALARM)inBurundi.

4 Community health worker (CHW) functionality assesments: A means to strengthen the health system in the region


29


TheEastAfricahealthandnutritionteamhasworkedwithNOstosupportengagementwithministriesof

healthtoprofiletheimportanceofCHWfunctionalityassessmentasakeyprocessincommunityhealthsystems

strengthening.Accordingly,representativesfromfiveNOhealthteamsandMoHdelegatesweresupportedto

attendthecommunityhealthworkerprogrammesustainabilityandscalabilitymeetingorganisedbyUSAID-HCIin

June2012.

CHWAIMproposes15programmaticcomponentsthathavebeenfoundtocontributetoaneffectiveCHW

programmebasedoninternationalbestpractices.Thesearerecruitment,CHWrole,initialtraining,continuing

training,equipmentandsupplies,supervision,individualperformanceevaluation,incentives,communityinvolvement,

referralsystem,opportunityforadvancement,documentationandinformationmanagement,linkagestohealth

systems,programmeperformanceevaluationandcountryownership.

Foreachofthe15components,fourlevelsoffunctionalityaredescribed:non-functional(level0),partiallyfunctional

(1),functional(2),andhighlyfunctionalasdefinedbysuggestedbestpractices(level3).

4.4Achievements

TheinitialassessmentsweredoneinNovember2011,andthesecontinuedthroughoutcalendaryear2012.Sofar15

assessmentshavebeenconducted,and27areplannedforFY13.(SeeTable6.)

Table 6: CHW functionality assessment status, December 2012

National office Funded by

Districts covered

Total # of districts in which WV is operational

Number of health facilities covered

Assessments planned for FY13

Number of assessments done

Burundi

Kenya

Rwanda

Tanzania

Uganda

Total

2

5

1

2

5

15

ALARM – AusAid

AIM – Irish Aid

EANMNeCH

Sponsorship

EANMNeCH-

AusAid

AIM

EANMNeCH

SUSTAIN-Canada

ADP budget

AIM

EANMNeCH

CHN campaign

2

1

1

3

1

2

1

8

6

25

8

55

13

21

30

127

2

11

9

0

1

4

27

19

15

22

11

15

133

68

283


30


TheseassessmentshavestrengthenedWorldVision’scollaborationwiththeWHO.InUganda,forexample,World

VisionworkedcloselywithWHOinconductingtheCHWfunctionalityassessmentalongsideahealthservices

availabilitymapping(SAM)intwodistricts.AlthoughWHOhadbeenconductingSAMsinUganda,theteam

mentionedtheyhadneverdoneanassessmentatthefirstlevelofserviceprovision.

InRwanda,WorldVisioniscloselyworkingwithWHOandtheMoHfortheassessmentsplannedforFY13.

Throughtheassessmentsconductedsofar,CHWprogrammefunctionalitywasfoundtoeitherbenon-functionalor

partiallyfunctional,afindingthatrevealstheneedtopayattentiontothisfirstlevelofserviceprovision,giventhat

WViscommunitybased.

Aconsistenttrendinfindings(14outof15assessments)isthatofhighestscoresinrecruitmentandinitialtraining,

withlowestscoresinequipmentandsupplies,supervision,incentivesandreferralsystem.

Forthevariousassessmentsdone,animprovementactionplanwasdevelopedasameanstofollowupprioritised

areasforsystemsstrengthening.KitgumDistrict,whereaspecialprojectwassolicited,isagoodexampleofwhat

happensoncethefunctionalityassessmentisdoneandanimprovementmatrixisdeveloped.

Case Study 3: Kitgum District in Uganda benefits from the CHW systems strengthening approach

TheEAMNeCHfive-yearprojectwasstartedinJuly2011withthepurposeofimprovingmaternal,newborn

andchildhealth(MNCH)inselectedcommunitiesfourEastAfricancountries:Kenya(KilifiDistrict),Rwanda

(GicumbiDistrict),Tanzania(KilindiDistrict)andUganda(KitgumDistrict).

Theprojectareaswerechosenbecauseofpoorhealthoutcomes,particularlyrelatedtoMNCHand

specificallyMDGs4and5.Theyhadweakhealthsystems,characterisedbyinadequategovernmentcapacity

torecruit,trainandretainmotivatedhealthpersonnelatboththecommunityandfacilitylevels.Health

informationsystemswereweak,withalackofinformationflowingfromcommunitiestotheMinistryof

Healthandviceversa.Despitemanyhouseholdsgrowingfoodforthemselves,nutritionknowledgearound

storageandusagewasinadequate.Accesstoappropriatesanitationservicesandhygieneknowledgewasalso

limited.PoliciesrelatingtoMNCHservicesexisted;however,theirimplementationinthefourprojectareas

wasweak.

ThemajorapproachfortheUS$9millionprojectisensuringincreasedaccesstoservicesthroughimproved

healthsystemstrengtheningandeducationatboththecommunityandfacilitylevel.

ThroughtheKitgumClusterInUganda,WorldVisionispartneringwiththeKitgumDistrictLocal

GovernmenttoimplementtheEAMNeCHprojecttocontributetotheimprovementofmaternalnewborn

andchildhealthinLagoroandMucwinisub-countiesby2016.TheprojectsupportstheDistrictHealthTeam

(DHT)inanendeavourtoimproveequitableaccesstoanddemandforMNCHservices

ByGeoffreyBabughirana,EAMNeCHprojectmanager,andAnitaKomukama,researchanddocumentationofficer


31


OneoftheavenuesthroughwhichaccesstoanddemandforMNCHserviceshasbeensolidifiedisthrough

thesupportoftheMinistryofHealth’scommunityhealthcaresystemofVillageHealthTeams(VHT).This

entailssupportingthelinkagebetweenthehouseholdsinthecommunityandthehealthsystemforincreased

accesstoMNCH.TheVHTmembersareempoweredtoeducateandpromotehealth-carepractices,

hygieneandsanitation;promotionofmaternalandchildhealth;conductactivecasefinding;appropriate

timelyreferraltothenearesthealthunit;andmobilisingforhealthservicesattheintegratedoutreachposts.

However,fortheVHTstobeabletocontributepositivelytotheaboveoutcomes,thedistrictneededto

knowthestatusoftheirfunctionality,usingtheMinistryofHealth2010VHTstrategyasthebenchmark.

UsingtheCHWAIMtool,theoverallassessmentrevealedthattheCHWprogrammeisatapartially

functionalstage.Supervision,individualperformanceevaluation,opportunityforadvancement,and

documentationandinformationmanagementwerefoundtobeincriticalneedofimprovement.

Whereastherewereseemingly321VHTmembers,255(79percent)didnotqualifytobeVHTsasthey

hadnotundertakenthefive-daybasictrainingasstipulatedintheUgandaVHTpolicy.Ofthe321whowere

doingVHT-relatedwork,47percentreportedhavingthebasictoolsandequipmenttoservethe7,617

householdsin120villages.

InterventionWiththefindingsfromtheassessment,theEAMNeCHprojectembarkedonadistrict-ledprocessto

implementasystematicVHTcapacity-buildingplan.Sincethen255VHTmembershavebeentrainedand

equippedwiththebasictoolkit(register,counsellingcards,participants’manualforreference,andreferral

form).VHTsdoqualityvillagewalksandtheyupdatetheirregistersonamonthlybasis.EachoftheVHT

membersisinchargeofatleast30households.

Tostrengthenthelinkagebetweenthehealthcentreandthecommunity,theprojectissupportingand

facilitatingVHTmonthlyreviewandstatusupdatemeetings.Onaverage,157VHTmembersinteractwith

thehealthcentrestaff.ThesemeetingsremindVHTsoftheirmonthlyschedules,includingmobilisationfor

outreaches,WASHimplementation,upcomingmassimmunisationcampaigns,qualityVHTvillagewalks,

updatingregisters,reportingandsubmissionofreports.

Aspartofthesupportofferedtothehealthcentrestocontributetothegovernment’sPrimaryHealth

Carestrategy,theprojecthasundertakentosupporttheVHTsastheyconductmobilisationandmonthly

outreachsessions.Atotalof30staticoutreachpostsarebeingsupportedeverymonthtoconductGMP,

ANCandprenatalcare(PNC)services.TwoVHTmembersonarotationalscheduleatthehealthcentres

supportthehealthworkersinthisregard.VHTsmobilisefortheseoutreacheswhenevertheytakeplace.

Achievements• Inaperiodof18monthsfollowingtheintervention,theoverallratinghasimprovedfrom42per

centto68percent.Thedistrictgenerallystillhasachallengewithtwocomponents:opportunityfor

advancement,andincentivesandremuneration.Theprojectispartoftheworkoftheteamthatis

facilitatingaVHTproductivitystudyconductedbyMoH;theplanisthatthiswillguidethesystemon

howtoprovideperformance-basedsustainablepayfortheVHTs.


32


• DatafromtheHMISfromJunetoDecember2012presentsevidencethat,duetotheintensification

ofintegratedoutreaches,230ofthe781FirstANCattendancesreceivedtheservicesthroughthe

outreaches,givinga29.4percentcontribution;ofthe434fourthANCattendances,146received

theservicesthroughtheoutreachservices,givinga33.6percentcontribution.Thisappliestoallthe

otherindicatorsintheHMIS.

• FromtherecentlyconcludedLotQualityAssuranceSamplingsurveyconductedandcomparingto

thebaselinesurvey,itwasestablishedthatVHTsupportofpregnantwomenhadincreasedfrom30.8

percentto42percent;coverageforcounsellingonferroussulphateandfolicacid(FEFA)forthelast

pregnancyincreasedfrom34.5percentto48percent;and17.5percentto61.1percentcoverageon

healtheducation(thatincludesdangersignsinpregnancyusingajobaid)forthelastpregnancy.Itis

alsoimportanttonotethatattendanceatoutreachGMPsessions,includingweighingandchartingthe

childhealthcard,increasedfromzeroto74percent.\

• DuetotheeffortsoftheVHTsindoingcommunitymobilisationforintegratedoutreaches,

cumulativelyforthereportingperiod(June2012–December,2012)4,817childrenhavebeenoffered

GMPservicesand791womenofferedANCservices,ofwhom376havetakenFEFAattheoutreach,

212havetakentheHIVtesttocontributetotheeliminationofmother-to-childtransmissionofHIV

(eMTCT),and415weregivenintermittentpresumptivetreatmentasapresumptivetreatmentfor

malariaduringpregnancy.Becausetheprojectisgendersensitive,40couplesweretestedforHIV;264

wereofferedPNCservices;264tookafamily-planningservice;and55menreceivedafamily-planning

service.

CostofinterventionSofar,overaperiodoftwoyears,thecostshavetotalledUS$40,943.Thisincludessupporttothe

integratedcommunityoutreach($3,700),monthlycoordinationmeetingwiththehealthcentrestaff

($12,300)andcapacitybuilding,includingtheVHTfunctionalityassessmentprocesses($24,943).


Successfactors

• Anewfocusoncommunityhealth,especiallyas2015drawsnearandMDGs4and5arefarfromreachingtheir

targets.Now,withtheonemillionCHWsinitiativelaunchedinJanuary2013,thereisawindowofopportunity

forembracingCHWs.

Gaps

• LimitedknowledgeofCHWpolicies,evenamongcadresofthehealthsystemthataremeanttoprovide

guidanceandsupporttoCHWs,isasetbacktoensuringfunctionalityofCHWsystems.

Challenges

• Theapproachdoesnotevaluatethequalityofservicesdeliveredbyindividualhealthworkers.Themethodology

reliesonsecondaryevidenceandself-reportsforassessment;therefore,informationcollectedcannotbeused

toevaluateindividualCHWperformanceorCHWcontributionstocoverage,effectivenessorimpact.


Our Contacts

World Vision InternationalEast Africa Region

KarenRoad,OffNgongRoad,P.O.Box133–00502Nairobi,Kenya

Forfurtherinformation:ContacttheHealthandNutritionLearningCentre

Email:[email protected][email protected]


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