Complementary Evaluation for EIP and Documentation of scale of Integrated Community Case Management in Rwanda - Key Findings - Presented by: Laban Tsuma, MD, MPH PVO/NGO Support Advisor MCHIP, Washington DC

Presentation Outline I.Background II.Objectives III.Methodology IV.Results V.Lessons Learned VI.Next Steps 2

Background EIP CSHGP Program: Focused on iCCM, CHW training, supervision and supply chain Encouraging peer support through modified care groups Contributions to Scale: Opportunity to learn about intervention(s) going to scale What was Rwanda’s planned versus actual pathway to scale for iCCM? How did EIP contribute to pathway? Cross-District Comparisons: Opportunity to compare quality of CCM delivered in EIP districts vs non-EIP districts Does the “modified care group” approach affect the quality of CCM? If so, how?

Objectives of Complementary Study Scale Study: To test the following Hypotheses NGO supported actions around HBM (2004) and iCCM (2007) were essential in leveraging MOH support for scale Strong leadership and political will in Rwanda were key in moving CCM to scale Comparative Study:  To assess status of CCM 4

Methodology The Complementary Study comprised of 2 different tasks.  Document Review + Qualitative elicitation of narratives by 17 key informants to “tell the story” of iCCM in Rwanda over time ( )  Qualitative assessment in one non-EIP district (Ruhango) targeting the following groups 5

Interviews and FGDs TargetDone Central MOH & Central Partners (USAID, UNICEF, WHO, PNILP, NGOs) 5 Technical persons1 MOH 11 NGO/Bilaterals District Health Officer1 Health professionals (Titulaire, CSC) 2 CHWsFGDs Mothers / Caretakers FGDs Cooperative OfficialsFGDs Focus Group Interviews

Results  A historical timeline for iCCM was elaborated. Also NGO contribution to some of these steps was mapped.  CHW Services are appreciated by both users and MOH.  Caregroups at the CHW level provide a natural peer support group and help with Community mobilization and BCC. 7

CCM Timeline in Rwanda – Abridged Version HBM Strategic Plan 2004 Expansion of HBM to 12 of 19 “endemic” Districts 2006 HBM Evaluations 2006 and 2007 using ACT iCCM Pilot in Kirehe 2007 iCCM Tool Development and revision Introduction of RDT at community level Expansion of iCCM to 30 Districts

1990’s PHC DIARRHEA MALARIA PNEUMONIA Home- based fluid and ORS and Zinc in Kirehe First pneumonia case treated by a CHW in the country in Kirehe district Feb 2008 POLICY CH Policy + community health desk RDT Policy Change Pilot AQ at village level in 6 districts Oct 07: Bukora HC, first ACT treatment by CHW HBM Strategic Plan C-PBF to incentivize CHWs EXPANSION Expansion of iCCM to 30 Districts CHW CCM Cadre mooted HBM TWG IMCI TWG MCH CH TWG takes over from IMCI TWG. Expansion of iCCM to 16 Districts 2008 (Phase 1) HBM in 6 Districts HBM in all 19 endemic Districts Individual CSHGP Projects are awarded to 3 NGOs

Other Critical Events for CCM in Rwanda 1  Vision 2020 Umurenge of 2000 and Decentralization Policy of 2001  Global Fund Round 3  WHO TA and HBM Strategic Plan 2004  NGOs piloting HBM, CORE/PMI support 2004  CHW Recognition by the Presidency - “Itorero” call; Cellphones 2008, IDHS

Other Critical Events for CCM in Rwanda 2  Setting up of MOH Community Health Desk; BASICS TA for iCCM Pilot 2007  Rwanda MOH exchange visit to Senegal to examine CCM 2006; Re-districting  Global Fund Round 5 –DHS 2005; CBHI  RCC and Global Fund Round 8; RDT Introduction 2009; C-PBF roll-out  C-PBF rollout; New staff cadre for CHW Supervision nationally; DHS

Lessons Learned 1  The EIP played a significant role in the scaling up of iCCM in Rwanda by intervening at critical points in the pathway to scale. 12

Lessons from Rwanda CCM evolution  HBM  Scaling CCM has been at 2 levels:- coverage or #districts, depth (+Pneumonia +Diarrhea +RDT +MUAC screening)  Clear MOH Policy and CH Desk  Strong Community confidence of CHWs and CCM program  Good funding levels via several partners including GF Rounds 3,5 RCC and 8, and PMI and USAID  Initial Planning always had scale in mind.  Rapid scale-up  Unique Innovations have been embraced like CBHI, c-PBF and SIScom

CCM Challenges that care groups could help alleviate  Quality of Case Management by CHWs: iCCM has more task competency requirements e.g. use of timer, MUAC, RDT  Quality of RDT process and result  Stock-outs of CCM meds at cell level  Low Frequency of Supervision by CSC at village level because of transport challenges  The decreasing frequency of CCM cases for CHWs may compromise proficiency

Lessons Learned 2 Immediate take home lessons for MCHIP following this study include consideration  -to support a validation study for CHW RDT application and reading;  - to co-opt peer support group formation and networking module in CHW training;  - for different CHW restocking models/ supervision models 15

Lessons Learned 3 Immediate lessons to global stakeholders include  -Increased efficiencies in the evaluation process due to shared resources and expertise of different but complementary partners;  -Shared learning/Adopting lessons learned into ongoing programs/Sustainability 16

Next Steps  Consider comparing DHS clusters from EIP and non-EIP areas from the recent DHS (2010)  Convene a face to face meeting for mutual agreement of CCM events timeline 17

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