Child Survival and Health Grants Program: Pearls of Learning from Eight 2013 Final Evaluations

Eight U.S. Agency for International Development (USAID) international non-governmental organization (iNGO) partners through the Child Survival and Health Grants Program (CSHGP) submitted final project evaluations in 2013. These partners include Center for Human Services (CHS), ChildFund International, Aga Khan Foundation (AKF), HealthRight International, Concern Worldwide, Curamericas Global, Medical Teams International (MTI) and CARE. These evaluations draw on a broad range of quantitative and qualitative project data, including monitoring and evaluation systems, with baseline and endline surveys; ongoing process documentation; operations research; and mid-term evaluations to generate learning and recommendations for governments, local civil society, other in-country stakeholders, iNGOs and USAID.

The evaluations can be found at individual links provided below or at the following link: CSHGP Final Evaluations.

A pregnant woman is transported in a chacana by a rural doctor and her neighbors.
A pregnant woman is transported in a chacana by a rural doctor and her neighbors.
Mario Chavez, CHS Ecuador
URC CHS

Center for Human Services, Ecuador
(2009–2013)

Nancy Sloan, Evaluator

Evidence for a network of care model produced by CHS influenced a decision by the Ministry of Health (MOH) for national expansion in Ecuador.

The evidence generated by the CHS for its innovative Essential Obstetric and Neonatal Care (EONC) network model influenced a decision by the MOH for countrywide expansion, including a dedicated budget and staffing. Inequities in health persist in Ecuador, with significant disadvantage among rural, less educated and indigenous groups who primarily receive maternal and newborn health care from traditional birth attendants, traditional healers and family members. In this context, the EONC network model coordinated community- and facility-based services (both public and private) to promote service delivery along the continuum of care and facilitated quality improvement by supporting parish health teams (including traditional birth attentants and facility providers), as well as district and provincial hospitals' quality improvement teams to monitor and improve the quality of care, including cultural appropriateness. This network led to improved behaviors for maternal and newborn health (including exclusive breastfeeding, recognition of postpartum and newborn danger signs and increased postpartum visits within 2 days of birth) and improved quality of care. In the final months of the project, CHS provided technical support to the MOH and updated maternal, newborn and child health quality standards and created a tool for quality management and an EONC toolbox with more than 60 tools (now being distributed nationwide). Project staff who provided this support are now employees of the MOH. The project was also recently highlighted in Spain’s main newspaper, El Pais. Read the Spanish language article and view the pictures.

The final evaluation, including the operations research report is available at the following link: CHS, Ecuador Final Evaluation [ZIP, 20.1MB].

Project and field staff at Hatillo UCOS.
Project and field staff at Hatillo UCOS.
ChildFund International
ChildFund International

ChildFund International, Honduras
(2009–2013)

Ramiro Llanque Torrez, Evaluator

Achieving greater health equity for women and children in Francisco Morazan Sur, Honduras.

Honduras is poised to improve its national health system and maternal and child outcomes by 2015; however, despite a clear intention by the Government of Honduras to include communities, equitable coverage of health services has not been achieved. To respond to this need ChildFund International set up UCOS, a unique community-based model, to improve health equity among rural, low-income beneficiaries in remote communities. As a result of project activities, child mortality in high-burden communities decreased from 33 per 1,000 live births in 2009 to 27 per 1,000 live births in 2012. Ninety-four percent of those who benefited from the UCOS were in the lowest socioeconomic quintiles, yet by the end of the project, these communities had higher child survival rates than communities at the department or national level. The UCOS, or health post, is staffed by an array of community volunteers, including trained traditional birth attendants, growth promotion monitors and community health volunteers. ChildFund International is in the process of expanding the model to 25 additional communities in the Department of Santa Barbara, as it offers a low-cost, policy-responsive service delivery model that meets the needs of high-burden populations. Results of a costing study conducted on the UCOS found that when families found solutions to a child health problem at the community- level UCOS, they saved from USD $6.03 to USD $70.24 (as opposed to visiting a rural health post or hospital, respectively). Similarly, the costing study found that resources could be “saved” by the government as a result of strengthening medical attention at the community level, from USD $6.07 at a rural health post to USD $33.13 at a hospital (per visit averted).

The draft of the final evaluation including the operations research report and costing study report is available at the following link: ChildFund International, Honduras Final Evaluation [ZIP, 8.1MB].

Photo by AKF Pakistan.
AKF Pakistan
Aga Khan Foundation

Aga Khan Foundation, Pakistan
(2008–2013)

Sohail Amjad, Evaluator

In collaboration with the Aga Khan Development Network (AKDN) agencies and the Khyber Pakhtunkhwa (KPK) provincial and Chitral district governments, the Aga Khan Foundation developed a public-private model to increase access to and demand for skilled care at the community level.

Global “progress has been much slower, and inequities in coverage much wider, for skilled attendant at birth and other interventions that require a strong health system. New approaches are needed that improve the quality of services, bring services closer to home and expand access to essential care.” (Countdown 2015) While Pakistan has had reductions in maternal mortality and increased the skilled birth attendance indicator to 40 percent, progress has been slow and is not on track to meet MDGs 4 and 5. Approximately 30,000 women continue to die annually of pregnancy- and childbirth-related causes in the KPK province, and 85 percent of deliveries take place at home. In the high altitude and geographically remote Chitral district of KPK province, AKF, in collaboration with the AKDN agencies and the Ministry of Health, responded to the call to prevent maternal deaths and improved skilled attendance at birth from 33 percent to 82 percent and skilled care across a continuum of care (minimum of one antenatal care visit, skilled attendance at birth and at least 1 postnatal care visit within 2 days of delivery) from 1 percent to 23 percent in areas of greatest need within a 5-year period. An innovative intervention package included improved training and deployment of community midwives, referral mechanisms, behavior change interventions, including male involvement, and community engagement and empowerment through village health committees (VHCs) and community savings schemes. Through training and an additional facility-based practicum, the project built community midwife (CMW) skills and confidence and bolstered relationships between community and facility health providers. The project fostered CMW linkages with community members and other community health workers (CHWs) through VHCs. It also assured service quality by establishing a supportive supervision system. Community-based savings groups (CBSGs) were introduced and found to hold promise for increasing utilization of skilled care, as women who were associated with CBSGs were four times more likely to access skilled care across a continuum of care. Referral mechanisms were strengthened as an outcome of connections fostered among CHWs and between community- and facility-level providers: Women were both referred to the CMW by other CHWs and referred on time to secondary facilities (supported in some cases by the VHC for transport). A significant recommendation from the evaluation to the provincial government is to utilize the project model to strengthen the community health workforce, in particular CMWs, and to extend AKF’s technical assistance to the government to adequately support and monitor the CMWs after the project ends. Deployment of CMWs is currently the only strategy to promote skilled deliveries in rural Pakistan, thus the evaluation recommends that the government also allocate sufficient funds to monitor CMWs and develop effective mechanisms to provide supervision. At a recent dissemination event, representatives from the KPK department of health committed to retaining the 28 CMWs deployed by the project. The draft evaluation includes two operations research study reports, one focusing on the utilization and retention of CMWs and the other, funded by DFID and AusAID’s Research and Advocacy Fund in KPK, on the role of CBSGs in increasing utilization.

The draft evaluation is available at the following link: Aga Khan Foundation Pakistan, Final Evaluation [ZIP, 14.8MB].

Focus group hold discussions with female community health volunteers in Khilji VDC, Arghakhanchi, Nepal.
Focus group hold discussions with female community health volunteers in Khilji VDC, Arghakhanchi, Nepal.
HealthRight International
HealthRight International

HealthRight International, Nepal
(2009–2013)

Chitra Gurung, Evaluator

In Nepal, HealthRight International improved the continuum of care through a new, integrated model of maternal and newborn care in facilities and communities.

HealthRight International implemented a community-based newborn care package in Arghakhanchi and Kapilvastu districts of Nepal that contributed to improved knowledge and behaviors, such as an increase in immediate drying and wrapping of newborns in each district from 63 percent to 79 percent and 33 percent to 72 percent, respectively, and an increase in four or more antenatal care visits in each district from 36 percent to 71 percent and 29 percent to 51 percent, respectively. HealthRight International also introduced and conducted operations research on a Maternal and Newborn Care Quality Improvement (MNC-QI) process in facilities. The targeted facilities showed improvements in quality indicators with an aggregate score of 80 percent or higher on the 12 MNC-QI tools implemented by the end of the project (nine tools on improving maternal newborn service delivery and three on improving skilled birth attendance training sites). The USAID mission in Nepal’s Health for Life bilateral project will adapt HealthRight International’s Quality Improvement model in modified version to support the Nepal Department of Health Services to institutionalize a nationwide system for quality improvement. HealthRight International also built the capacity of Health Facility Management Committees, working with Village Development Committees (VDCs) to appropriately oversee and allocate local resources (human resources and cash), leading to improved health facility performance. The Health Facility Management Committee strengthening program has been scaled up by the District Health Office to additional VDCs in one of the project districts and by Health for Life in additional districts (14).

The final evaluation including the operations research report is available at the following link: HealthRight International, Nepal Final Evaluation [ZIP, 11.9MB].

A Care Group volunteer conducts a home visit.
A Care Group volunteer conducts a home visit.
Adele Fox, Concern Worldwide
Concern Worldwide

Concern Worldwide, Burundi
(2008–2013)

Bonnie Kittle, Evaluator

In Burundi, Concern Worldwide effectively extended the reach of the health system’s community health workers (CHWs).

Concern Worldwide integrated a Care Group approach of women volunteers to extend the reach of CHWs and to achieve improvements in key child health and nutrition behaviors. This research is very relevant to the global health community because the traditional Care Group approach (facilitated by international non-governmental organizations [iNGOs]) has been proven to be effective in reducing child malnutrition rates. It is also currently being employed as a behavior change strategy in more than 20 countries. The operations research study tested whether an integrated Care Group model, organized through the health system and led by Ministry of Health (MOH)-supported CHWs, was as effective as the traditional iNGO-facilitated Care Group model when comparing 40 key child health and nutrition knowledge and practice indicators. For example, in both intervention groups, mothers’ knowledge of when to begin complementary feeding showed significant increases from baseline to endline from 75 percent to 90 percent in the integrated Care Group model and from 69 percent to 86 percent in the traditional Care Group model. This suggests that the MOH-supported CHWs in the integrated Care Group model were just as effective in training and supervising their Care Groups compared to the iNGO-paid promoters in the traditional Care Group model. Further discussions are under way with the Department of Community Health to consider integrating Care Groups into the health system more widely.

The final evaluation including the operations research report is available at the following link: Concern Worldwide, Burundi Final Evaluation [ZIP, 18.9MB].

Project staff conduct focus group discussion with trained traditional midwives.
Project staff conduct focus group discussion with trained traditional midwives.
Jean Capps, Curamericas Global
Curamericas Global

Curamericas Global, Liberia
(2008–2013)

Jean Capps, Evaluator

Community-generated and -owned data combined with mobile rural health teams supported by Curamericas Global significantly improved immunization coverage in rural Liberia.

In rural Nimba County, Liberia, Curamericas Global implemented an approach built on its innovative Census-Based Impact Oriented (CBIO) methodology, mobile Primary Health Care Teams and targeted behavior change communication (BCC) based on initial barrier analysis and implemented using the Care Group model. Curamericas Global mobilized the community using the CBIO methodology by conducting a participatory data collection and monitoring process to allow tracking of service use (or lack of use) over time utilizing community registers, while the mobile health team approach brought services directly to the community along with targeted BCC. These combined approaches resulted in improvements in multiple health behavior and coverage indicators, for example, vaccination coverage; by the end of the project, household survey results found significant improvements indicating that 97 percent of children (12–23 months) had received measles and PENTA 3 vaccinations. Key in-country partners will share this model and associated results with the county health team.

The final evaluation is available at the following link: Curamericas Global, Liberia Final Evaluation [ZIP, 5.2MB].

ECD Peer Educator Tonny Anyang of Apua Parish teaches a mother about baby cues.
ECD Peer Educator Tonny Anyang of Apua Parish teaches a mother about baby cues.
MTI
Medical Teams International

Medical Teams International, Uganda
(2009–2013)

Sue Leonard, Evaluator

Medical Teams International (MTI) Uganda achieved improved health practices and quality of care by strengthening the relationship between community systems and the district health system.

MTI built the capacity of community health systems structures (Village Health Teams, mother’s groups, Parish Development Committees, Health Unit Management Committees and health facilities) to collaborate to promote key family health and child development practices, referrals and community case management. Household- and community-level practices improved significantly as did health provider quality of care indicators. Maternal and child health service delivery and management at the health facility and health promotion at community levels also dramatically improved. Survey findings indicate more women are delivering with skilled attendants (from 35 percent at baseline to 84 percent at endline) and the number of women with four or more antenatal care visits has increased (from 35 percent to 58 percent), reinforcing comments in the focus groups about the improved attitudes of health providers. District and local government structures are assuming responsibility for continuing the interventions.

The final evaluation is available at the following link: Medical Teams International, Uganda Final Evaluation [ZIP, 19MB].

PRI Pradhan gives food to TB patient. Photo by Soumen Pandey, CARE.
PRI Pradhan gives food to TB patient.
Soumen Pandey, CARE
CARE

CARE, India
(2008–2013)

Ambarish Dutta, Evaluator

Improved linkages between private providers, community volunteers, TB and HIV programs, and local self-government systems supported the national TB control program to improve TB testing, treatment and patient support.

Gaps in the national TB control program (RNTCP) in West Bengal included low case detection; barriers to accessing facility DOTS (directly observed treatment, short-course), including distance and migration of patients; weak coordination between TB and HIV programs; and general lack of awareness of TB. In order to bridge these gaps, CARE employed the following major strategies: 1) engagement of rural health practitioners (private providers) to ensure early referral of TB suspects to RNTCP; 2) involvement of community volunteers for identification of suspects and provision of DOTS; 3) creating linkages between local self-government systems (PRIs) for access to social welfare schemes; and 4) encouraging coordination between TB-HIV programs through sensitization of both sets of staff. Referral of patients from private providers had previously been a contentious issue. (This is perhaps the first time in West Bengal that this resistance was overcome and these referred TB suspects were directly tested with sputum microscopy by the RNTCP thus creating an opportunity in the future for more referrals from other providers outside the government system.) The community volunteers played an important role to intensify the treatment compliance of retreatment patients. The default rate for retreatment patients in one project area dropped to zero in the last few project quarters due to intensified support. District-level policy-issuing bodies for PRIs in a few districts have designed a standard framework for support to TB patients. Finally, the project also raised counseling and testing of TB patients for HIV in some districts to 70 percent.

The final evaluation is available at the following link: CARE, India Final Evaluation [ZIP, 2MB].

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Last updated: April 09, 2014

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