EOP Evaluation of BASICS iCCM Project Benin 2009 to 2012

USAID funded MSH implemented

Freeman PaulDeussom GabrielParaïso M Noël

Glèlè Yolaine

Acknowledgements• USAID Washington and USAID Benin• Ministry of Health Benin & Staff, National, 5 HZs• MSH Basics staff Parakou• Project Partners 5 NGOs & Africare, UNICEF, CRS• Bryan Comstock U of Washington- sampling• Community members, surveyors, supervisors 6 HZ

Disclaimer. All views expressed are those of the authors and do not necessarily reflect the opinion of USAID or the GH Tech team.

Idea for CC study from USAID Benin but all design, implementation and write up by team.

Benin

• Infant MR 73/1000 Child MR 115/1000 -2012• Malaria, ARI, diarrhea, anemia < 5 mortality• 47% of rural children < 5 stunted – 2012• 20% of rural children < 5 sleep under ITN-2012• Health Workforce Density < 0.05 /10,000p -2012

FrancophoneTraditional MuslimPopulation9, 100,000 (2011)DemocracyLife E at B 56.8yrsFertility 5.1 c/w

Project Interventions

• iCCM c.s. CHWs rural villages > 5 km from H. F.• Coordinate with MOH, UNICEF, Africare--CHW• Rx Malaria, ARI, diarrhea, refer/escort to HCs• CHWs home visits link mothers with HCs• CHWs ed about/support EPI, ITN• Supervisors/Educators/Drug Supply local HCs• Community based information system HCs• Local NGOs support CHWs –ESP remote areas

Project Site Northern Benin

5 Health Zones93 Health Centers

1048 CHWs trained193 trainer/supervisors

trained

202,116 Infants less than 5 yrs

~16-20% of the under 5 population of Benin

5 local NGOs associated with the project

Began :30 July 2009 Ended : 29 Ju;y 2012

34 / 36 Months

HZ Tchaourou

BORGOU

HZ Bassila

DONGA

HZ Djougou-Ouaké-Copargo

DONGA

COVADES

HZ HZ Kandi-Ségbana-

Gogounou

ALIBORI

HANDICAP PLUS

HZ Banikoara

ALIBORI

CBBE

GRADE

DEDRAS

Project Cost: $ 4,377,056

Evaluation Questions

• Coverage and quality of iCCM delivery

• Capacity and sustainability of HZs and local NGOs to support CHWs

• Achievement of project objectives & activities

• Lessons learned and best practices.

Evaluation Methods• Three intervention HZ selected- Kandi, Tchaourou, Djougou• Key Informant Interviews- at all levels- MOH, local partner NGOs,

UNICEF, Africare, CRS, others.

• Focus Groups- CHWs, mothers, community • leaders, HC staff• Document review

• Case Control study

• Standardized Observation of Clinical Skills of 120 CHWs Observation Checklist Source. Adapted from Community based Distributors Quality of Care Assessment IRC 2011

Case Control Study

• 3 Intervention HZs compared w 3 control HZIn villages 5 to 10 km from local HC in South • 30 clusters of 10 mothers w children < 5 who

had fever, cough, or diarrhea in the past two weeks versus 30 clusters of 10 control HZ (600 total)

• CHWs not trained in iCCM present in control.• Sampling power 80% to show differ > 10% • Standardized questions – trained interviewers

ResultsCHW Coverage Level by Health Zone

  Banikoara Bassila D-C-O K-G-S Tchaourou Total

Total villages (>5kms)

462 104 472 348 330 1716

Covered Villages (>5kms)

181 54 250 147 109 741

RC/HZ trained

186 108 360 223 172 1049

%

coverage

39% 50% 69% 42% 33% 43%

Source: Project Data, January 2011, BASICS.

Total numbers of cases treated by CHWs

Number of Children agedLess than 5 yearsTreated by CHWs

During project Treated for Male Female Total

Malaria 22357 19467 41824

Diarrhea 2497 2220 4717

Source .Project CHIS Cough/Pneumonia 3742 3461 7203

Household Homevisits by CHWs

FY 2011 FY20120

5000

10000

15000

20000

25000

30000

35000

40000

Household Visits by CHWs

Case Control General Results

• Demographics of guardians same by sex, age• Mothers home only I 183 (63%) v C 110 (37%• Education no F.ED I 264 (86%) v C 181(62%

• There were CHWs untrained in iCCM in control• 236 mothers sought HC for child from CHW in

intervention area c/w 108 who sought HC from CHW in control

Person/s Approached for Initial Care INTERVENTION CONTROL TOTAL

CHW 240 (78.7%) 108 (36.2%) 348 (57.7%)

Health Center 26 ( 8.5%) 95 (31.9%) 121 (20.0%)

Local Store 15 ( 4.9%) 82 (27.5%) 97 (16.0%)

Traditional Practitioner

4 ( 1.3%) 9 ( 3.0%) 13 ( 2.1%)

Parent/Friend 20 ( 6.6%) 4 ( 1.4%) 4 (0.7%)

305 (100%) 298 (100%) 603

Time Delay Before Seeking Health Care In Intervention And Control Areas

INTERVENTION CONTROL

Delay in seeking health care

Less than 12 hours 117 (49.6%) 11 (10.2%) 128

12 to 24 hours 77 (32.6%) 36 (33.3%) 113

24 to 48 hours 25 (10.6%) 46 (42.6%) 71

More than 48 hours 17 ( 7.2%) 15 (13.9%) 32

N 236 (100%) 108 (100%) 344

Use Of Health Care Before The Presence Of local CHW Compared With Control

Initial Source of health care

INTERVENTION

CONTROL Total

Health Center

147 (61.25%)

86 (79.63%)

223 (66.95%)

P = 0.000

Self-Medication

67 (27.92%)

43 (39.81%)

110 (31.16%

P = 0.027

Traditional Practitioner

3 (1.25%)

10 (9.265) 13 (3.74%)

P = 0.000

N 240 (100%)

108 (100%)

348

Mothers’ Perception Of The Benefit Of Having CHW Care For Their Children

Project CONTROL Total

CHWs live nearby 193 (80.42%)

76 (70.37%)

269 (77.3%)

P = 0.038

Accessibility to health care

177 (73.75%)

53 (49.07%)

230 (66.09%)

P < 0.0001

Availability of medications

130 (54.17%)

62 (57.41%)

192 (55.17%)

P = 0.57

240 (100%)

108 (100%)

348

Mother’s perception of the quality of care given by CHW

PERCEPTION INTERVENTION CONTROL

Correct treatment given by CHW

90.5% 70.3%

Satisfied with health care given

97.5% 87%

Access to follow up health care valued

50% 23.1%

Skills of CHWs observed

• Simulation of the examination a two old child presenting with fever (Real mothers and child)

The 119 RCs observed: • Asked

– about the age of the child in 94%, – about fever in 93%, – about diarrhea in 82%, respiratory symptoms in 75.6% – and length of time of symptoms in 94% of cases.

• Examination– 49.6% uncovered the child’s chest– 51% counted the child’s respiratory rate using a counting device.

Use of LLIN by Project Households

•

0

1000

2000

3000

4000

5000

6000

7000

8000

Oct-1

0

Nov-

10

Dec-

10

Jan-

11

Feb-

11

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Oct-1

1

Nov-

11

Dec-

11

Use of LLIN by Households in the Community

Children having slept undera LLIN the previous night

Households with a LLINconfirmed installed

Major Implementation Lessons

• Collaboration – regular contact- CHW same• Local NGOs• Work AIDS – job, supervision, HIS HZ comp• CHWs locally chosen—CHW referrals followed• Local links-community-HC-HZ-central MOH• Collaborative supervision

Local NGO members

22

Workaids Developed by Project

Supervision Clinical Skills

• July 2011 assessment of CHW clinical skills found widespread deficiencies

• Collaborative Approach developed.• Individual coaching of CHW on-site and • during CHW visits to local HC using Check List

At HC visits CHWs give one another feedback/help.Within each village local quality teams established to work with local CHW.

Performance of the CHWs and Supervisors in Clinical Assess. On FU.

020406080

100

Results Obtained

Post Training Follow-upSupervision at 3 monthsSupervision at 6 months

Evolution of the Copargo Commune CHW performance within 6 months of the implementation of the Collaborative Ap-

proach

Hidden details

• 85% of CHWs were male

Thank you ! The team

Reasons Given for not using CHWs

Reasons given for

not using CHW

Intervention Control TOTAL

Nil answer given 15 (23.0%) 32 (16.8%) 47 (18.4%)

Do not use them 19 (29.2%) 80 (42.1%) 99 (38.8%)

Absence of information about CHWs

18 (27.7%) 55 (28.9%) 73 (28.6%)

They are not available 13 (20%) 23 (12.1%) 26 (10.1%)

N 65 (100%) 190 (100%) 255 (100%)