1. A Scalable Model for Community Health Worker Motivation

2. Project Overview
Implemented from 2007 – 2011 in six districts in Rwanda
Target population: 300,000 children under five
Objectives:
Increase access to first line treatment for malaria, pneumonia, and diarrhea through scale-up of CCM
Increase coverage of prevention interventions
Increase adoption of key family health practices

3. Rwanda MoH Community Health Structure
District Hospital: Community Health Supervisor
Health Facility: In-Charge of Community Health
CHW Cooperative and Cell-Coordinators
Community-based approaches for BCC are often not brought to scale because of the amount of financial and human resources required. Mass media is usually relied upon to provide wide-spread messaging.
Village Level: 2 ‘binomes’ for c-IMCI; 1 CHW for Maternal Health, and 1 Social Affairs Officer

4. Existing CHW Supervision and Reporting Structures
Sector
In-charge Community Health
Cell
Cell coordinator
Volunteers make household visits – ideally twice a month
Health messages are phased in. This often involves starting with “easier” messages such as treatment of diarrhoea and care-seeking for illness, then moving to more difficult topics like infant feeding.
The Care Group promoter sets group goals, so the volunteers must work together to achieve their targets
1 hour to 1 day walk
40-80 Villages

5. Opportunities for Improvement
MOH has clearly defined Community Health structure that includes CHWs
CHWs are officially recognized in the community, motivated, and provided incentives (Cooperatives)
But …
Challenging reporting and supervision structures
Volunteers make household visits – ideally twice a month
Health messages are phased in. This often involves starting with “easier” messages such as treatment of diarrhoea and care-seeking for illness, then moving to more difficult topics like infant feeding.
The Care Group promoter sets group goals, so the volunteers must work together to achieve their targets

6. Kabeho Mwana Community Health Structure
In-Charge Community Health
Cell Coordinator
CHW Group
CHW Group
CHW Group
CHW Group

7. 660 peer support groups formed with 13,166 CHWs in 6 districts
Outputs
660 peer support groups formed with 13,166 CHWs in 6 districts
Average of 163,000 households visited on a monthly basis with key prevention messages
Care Groups are supported by 152 Community Health Workers (2 Care Groups per CHW, or 20 volunteers)
CHWs are trained and supported by 22 health facility staff in 11 health facilities.
The topics that have been rolled out so far are: prevention and treatment of malaria; prevention and treatment of diarrhoea; nutrition is underway; management of pneumonia planned for April
Key Operational Indicator
Traditional Care Group Area
(June –August 2011)
Integrated Care Group Area
Average number of Care Group meetings per month in the previous quarter
1.7
2.0
% of Care Groups had at least 80% Volunteer attendance in at least one meeting per month in the previous quarter
81%
93%
% of households with children <5 years of age or women of reproductive age have received at least one household visit by a Care Group Volunteer per month in the previous quarter
96%
78%
% of trained CHWs submitted completed monthly reports on CGAIs and C-HIS to Health Centers per month in the previous quarter
89%
87%
% Care Group Volunteers reported on C-HIS data to CHWs/Health Promoters per month in the previous quarter
94%
98%

8. Outcomes Supervision and Reporting: CHW Activities:
Peer supervision helped to compensate for health facility staff challenges (HR, transport)
Monthly meetings provided opportunity for facilitated supervision from In-Charge Community Health or Cell Coordinator
Reporting burden on Cell Coordinator greatly reduced
CHW Activities:
Provided CHWs with greater social support (small groups vs. large cooperatives)
Groups perceived as motivating factor
IGAs
C-HIS only started being rolled out towards the end of 2011, so there are limited data on its use and sustainability at the moment
C-HIS is another useful tool for preventing volunteer drop-out – working together to compile report for a data

9. Integration with MoH Structures
MOH stakeholders, CHWs, and beneficiaries viewed CHW peer supervision and support model as part of MOH-endorsed, cell-level CHW Cooperative structure at a smaller scale
Volunteers make household visits – ideally twice a month
Health messages are phased in. This often involves starting with “easier” messages such as treatment of diarrhoea and care-seeking for illness, then moving to more difficult topics like infant feeding.
The Care Group promoter sets group goals, so the volunteers must work together to achieve their targets

10. Conclusions CHWs working as group: Lessons on Scale:
Provide greater peer support through social cohesion
Encourage joint problem solving
(In Rwanda), provide mechanism for BCC and home visits that would not exist otherwise
Lessons on Scale:
Working at district level first, in collaboration with TWGs
Decentralization – districts chose to adopt
Transition to country ownership

11. Next Steps
The CHW Peer Supervision and Support Model provides a scalable model for meaningful engagement of CHWs at the village level - where it counts!
August 2011 final evaluation recommends testing and institutionalizing CHW peer support model as means to increase CHW motivation