Enhancing Community Level Health System through the Care Group Approach

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Kelley Briggs
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1 Enhancing Community Level Health System through the Care Group Approach USAID-funded Title II Food for Peace Development Food Assistance Program Knowledge Sharing from FH /ORDA s Health and Nutrition Interventions

2 Project overview Outline MOH health service delivery system (HSDS) Care group alignment with HSDS Major achievement Key result Response to implementation challenges 2

1985; FHE has 30+ years of experience FHE is currently managing development and relief

3 About Food for the Hungry-Ethiopia (FHE) FH is a Christian Relief and Development Organization working in more than 20 countries worldwide Operation in Ethiopia since 1985; FHE has 30+ years of experience FHE is currently managing development and relief programs in the regions of: Amhara, SNNPR, Oromia, and Benishangul Gumuz FHE has over 350 staff 3

4 Operation Area Nine Wordeas/Districts Targeting 72,000 pregnant and lactating women (PLW) with behavior change communication through Care Groups

5 Goal, Objectives, Intermediate Results (IR) and Approaches GOAL Improve the food security status of all members in food insecure households in nine woredas. STRATEGIC OBJECTIVES: SO1: Health and Nutrition of Women and Children under Five in the Target Woredas Improved SO2: Community Resiliency to Withstand Shocks Improved 5

6 SO1: Health and Nutrition of Women and Children under five in target Woredas Improved IR 1.1: Maternal and Child Health and Nutritional Practices of Pregnant Women and Mothers of children under 2 Improved IR 1.2: Access to Nutritious Foods Improved IR 1.3: Access to Water and Sanitation Improved 6

7 Strategy/Approach Promote behavioral change using Care Groups (small peer-to-peer groups of lay women volunteers who systematically disseminate health messages to her neighbors) Strengthen health system by building woreda staff capacity Educational entertainment at Public Works Days/schools Identify key determinants through barrier analysis Enhance household food diversification Promotion of Community Led Total Sanitation 7

8 The Health and Nutrition Targets Most vulnerable groups 72,104 direct beneficiaries/plw Influencers - total of 201,530 addressed through community dialogue and Care Group sessions Community at large of about 566,444 through educational entertainment Total of 462 Care Groups, consisting of 5,546 Care Group volunteers across 9 districts and 151 kebeles 8

9 Ethiopia Health Care Delivery System 9

10 Health Extension Program Ethiopia has embarked on the Health Extension Program (HEP) a community based strategy to deliver health promotion, disease prevention and some curative health services at the community level HEP improves health service utilization by linking communities with health facilities/health centers The HEP has 16 health packages categorized into four major components: promotion of hygiene and environmental sanitation, prevention and control of major communicable disease promotion and provision of family health service health education and communication 10

11 Continuation 38,000 health extension workers (HEW) have been trained & deployed, all women 2/kebele Considering subdivisions within kebele are beyond the of HEW, MOH also assigned women health development army (WHDA) Selection criteria for WHDA s capable of leading 1:30 or 1:5 network willing to work as a volunteer, female, age less than 50 respected by the community and good relationship with community desire to serve their neighbors, models in the implementation of health packages (good hygiene, sanitation, and nutrition practices) 11

Cascaded Care Groups aligned to MOH Structure WHDA 30 WHDA 30 WHDA 30 District HO: HEW Supervisor & NCHO HEW FH/O Animator WHDA WHDA WHDA WHDA 30 30 30 30 GoE MOH Supported FH/O Health Officers

12 Cascaded Care Groups aligned to MOH Structure WHDA 30 WHDA 30 WHDA 30 District HO: HEW Supervisor & NCHO HEW FH/O Animator WHDA WHDA WHDA WHDA GoE MOH Supported FH/O Health Officers provide input WHDA WHDA FH/O Supported FH/O Health and Nutrition Officer WHDA WHDA WHDA NCHOs and HEW Supervisors train HEWs HEWs & FH/O Animators train ~12 WHDAs Each Volunteers (WHDA) trains 30 HHs via CG approach and BCC to PLW through small group education and home visits. 12

13 Continuation FH adopted CG approach in to HEP system using WHDA to lead CG session Supported district health office in identification of WHDA WHDA who were PLW and fulfill the criteria were given priority to lead CG session Organized and trained more than 5800 WHDA 13

14 HEW/FH Animators jointly training WHDA 14

15 WHDA Leading CG Session to PLW 15

16 WHDA Cascading CG Session to PLW Groups 16

17 IR 1.1 Maternal and child health and nutritional practice of pregnant women & mother of CU2 improved Major activities.. heath workers capacity building for key district health workers and HEW promotion of essential nutrition actions (ENA), essential hygiene actions (EHA), maternal, newborn and child health (MNCH) BCC through Care Groups for PLW using structured modular session on monthly basis address influencers with key messages using CG 17

ENAs: Micronutrients (2 lessons) Module #3 Essential care to mother during pregnancy, delivery, postpartum (6 lessons)

18 Modular Sessions for CG session Module #1: Care Group orientation (2 lessons) Essential Nutrition Action (ENAs): Prenatal Nutrition & Breastfeeding (5 lessons) Module #2: ENAs: Complimentary Foods and Feeding of the Sick Child (6 lessons) ENAs: Micronutrients (2 lessons) Module #3 Essential care to mother during pregnancy, delivery, postpartum (6 lessons) Module #4: Essential Hygiene Actions (EHAs): Personal, Environmental and Water and Food Hygiene (5 lessons) Total = 26 lessons 18

19 Major activities Educational Entertainment - to reinforce key ENA/EHA messages promoted among PLWs 19

20 Micronutrient/ Vit A Rich Fruit Promotion 21

21 Promotion Of Consumption of Animal Protein 22

22 Promotion of Vegetable Consumption 23

23 CGs Contributing to Self-Help Group Development Mothers discussing on the module and contributing monthly savings 24

24 Major activities IR 1:3 Access to water and sanitation improved Development and maintenance of potable water supply Promote EHA -focusing on food and water handling Promote Community Led Total Sanitation/CLTS - A community based approach to rural sanitation that facilitates recognizing the problem of open defecation and taking collective action Pre-triggering (selecting a community, creating awareness and building understanding); Triggering (participatory sanitation profile analysis, ignition moment) Post triggering (Action planning by the community and follow up) 25

25 Community Led Total Sanitation Village mapping and discussion 26

26 Monitoring Tools Monitoring Visits monthly by project and quarterly by Health Officer Annual Knowledge Practice Coverage (KPC) surveys Pre and post tests for each training event Quality Improvement and verification checklists (QIVC) for each lessons and training sessions Regular follow up of PLWs for identification and certification of model mothers who adopt all essential practices promoted by the project 27

27 Contribution of CG in Strengthening the Local Health System o CG volunteers (WHDAs) are empowered in group facilitation & negotiation skill o CG increased the number of trained community health workers (WHDAs) on nutrition, maternal and child health, hygiene and sanitation. o It ensured the functionality of 1:30 network o Used as a forum to disseminate other health related information o Identify pregnant women and encourage for ANC, health facility delivery, PNC,... o CG served as a forum for increased uptake of health service 28

28 Other Benefits of CG o Enabled women to interact, socialize and support each other o It also created an opportunity for women to discusses on different health issues o Continuation of specific program activities and services, coupled with SHG activities has shown a good prospect of sustainability in the first cohort of the program, more than 60 % of PLWs have continued discussing on health and nutrition sessions nearly three years after program phase out from target Kebeles. 29

29 Project Achievement WHDA reached nearly about 63,000 PLW in nine districts from chronic food insecure regions of Amhara. Targeted PLW have been intensively counseled on appropriate breastfeeding and complementary feeding practices through CG over a two years period of the program implementation. Jointly with district health offices, has substantially contributed in improving the capacity of more than 5800 WHDAs and 300 HEWs in 150 kebeles in nine districts. 30

30 Continuation Addressed 81% of targeted PLW through BCC using CG (62,927 out of 72,103) The project certified 85% (51,070 PLW) of the targeted mothers as models 31

Achievement from Mid-term Evaluation/Review (MTR) o HEW and WHDA successfully supported MOH priorities by providing and reinforcing key maternal and child health and

31 Achievement from Mid-term Evaluation/Review (MTR) o HEW and WHDA successfully supported MOH priorities by providing and reinforcing key maternal and child health and nutrition messages through the CG model o WHDAs showed particularly strong knowledge regarding latrine usage, hand washing, EBF and basic complementary feeding practices 32

32 Achievements from KPC The project has scored improved trends of first hour breast feeding based on KPC survey conducted in four consecutive years, from 60.5% in the first year(2013) and 74.9% in the final year of the program(2016) Percentage of mothers/care givers practicing prelacteal feeding has decreased from 13.9% in the first year(2013) to only 3.1% in the final year of the program(2016) Improved initiation of complementary feeding among children 6-23month, from 77.1% in the first year(2013) and 94.3% in the final year of the program(2016) 33

33 Achievements from KPC Increased frequency of meals during pregnancy from 23.4% in the first year (2013) and 38.1% in the final year of the program(2016) Percentage of mothers who had at least one ANC visit has increased from 49.6% in the first year (2013) to 83.3% in the final year of the program(2016) 34

34 Response to implementation challenges Change of trained VCHW to WHDA during the course of the project period High illiteracy level of WHDA Negotiation and adaptation to the system Assisted to remember key messages, assist by their children or someone from CG members 35

35 THANK YOU!!

GOAL ETHIOPIA Sidama Child Survival Program MID-TERM EVALUATION REPORT. Awassa Zuria and Boricha Woredas of the SNNP Region of Ethiopia

GOAL ETHIOPIA Sidama Child Survival Program MID-TERM EVALUATION REPORT Awassa Zuria and Boricha Woredas of the SNNP Region of Ethiopia COOPERATIVE AGREEMENT # GHN-A-00-07-00010-00 START DATE September