The document summarizes an operations research study conducted in Burundi comparing a traditional Care Group model led by NGOs to an "Integrated" Care Group model led by the Ministry of Health. The study found that: 1) The Integrated model achieved similar improvements in knowledge and health practices as the traditional model. 2) The Integrated model functioned as well as the traditional model in terms of volunteer attendance and household visits. 3) The Integrated model showed potential for sustainability similar to the traditional model during the initial post-project period. The Integrated model integrated Care Groups into the Ministry of Health structure using community health workers and showed promise for increasing scale and sustainability while building local capacity.

1. Integrating Care
Groups into
Government Structures:
Learning from an
Operations Research
Study in Burundi
Jennifer Weiss; Health
Advisor, Concern US
Delphin Sula; Health
Program Manager,
Concern Burundi
Care Group Technical
Advisory Meeting
May 29-30 2014

2. Overview of Presentation
 Description of Concern’s ‘Integrated’
Care Group Model
 Overview of Operations Research Study
 Results of Operations Research Study
 Learning and Implications

3. Why Adapt the Model?
What We All Know:
 Care Groups have been
implemented by more than 20
organizations in approximately 25
countries with excellent results
 Evidence-based strategy that has
significantly contributed to improved
child health and nutrition outcomes.
 Davis, T. et al (2013). Reducing child global undernutrition at
scale in Sofala Province, Mozambique using Care Group
Volunteers to communicate health messages to mothers.
Global Health Science and Practice.
 Edward, A. Et al (2007). Examining the evidence of under-
five mortality reduction in a community-based programme in
Gaza, Mozambique. Transactions of the Royal Society of
Tropical Medicine and Hygiene.
With Opportunity for Improvement…
 NGO-lead model: what happens
when the project ends?
 Integration with Ministry of Health
systems: increases opportunities for
scale and sustainability

4. Background to Child Survival Project
• USAID CSHGP-funded project in
Mabayi District, Cibitoke Province,
Burundi
• October 2008 – September 2013
• “Innovation” grant with OR component
• Technical interventions: malaria,
diarrhea, pneumonia, IYCF

5. The ‘Integrated’ Care Group Model
National
level MOH
Cibitoke
Province
Mabayi District
Health Team
Mabayi District Health
Facilities (25)
Community Health Workers
(152, approximately 4 per
health facility)
Household level
(estimated 107,000 WRA and CU5)
Project Objectives:
1. Improved household maternal
and child health care and
nutrition practices
2. Improved access to quality
child health care services with
a balance of provision at the
health center and community
levels
3. Strengthened community
leadership in health

6. The ‘Integrated’ Care Group Model
CHWs instead of
Promoters
Key difference: CHW only
supervises 2 CGs
DHT is trained by NGO
staff to serve in
‘Supervisor’ role

7. Operations Research Study: Methods
Cluster randomized, pre-post study
Traditional
Area
Integrated
Area
# Care Groups 51 45
# Care Group Volunteers 503 478
# Children Under 5 and
Pregnant Women 7,758 6,630

8. Operations Research Study: Questions
1. Does the Integrated Care Group model achieve at least the same
improvements in key knowledge and practices as the traditional
model?
2. Does the Integrated Care Group model function as well as the
traditional model?
3. Is the Integrated Care Group model as sustainable as the traditional
model?

9. Care Group Activities
Care Group Activities in Both Study Areas
• Care Group Meetings 2x month
• Facilitated by Promoter in Traditional
• Facilitated by CHW in Integrated
• Home visits to Neighbor Women at least 1x per
month
• Collection of household data (illness, death)
MODULE TOPICS
Nutrition
 Definition and consequences of malnutrition
and screening for malnutrition
 Recognition of complications and danger signs
of malnutrition
 Nutrition and micronutrient supplementation
during pregnancy
 Immediate and exclusive breastfeeding for
children 0-5 months
 Complementary feeding for children 6-8
months and 9-23 months
 Food groups (strength, energy, micro-nutrient)
 Micronutrient supplementation for children
Malaria
 Malaria transmission, symptoms, and danger
signs
 Malaria in pregnant women: consequences
and complications
 Care-seeking for malaria
Diarrhea
 Diarrhea symptoms and danger signs
 Home-based management of diarrhea
 Hand-washing practices; how to build a tippy-
tap
 Water treatment and food hygiene
Pneumonia
 Definition, danger signs, and care-seeking
 Home practices to prevent pneumonia
Key Difference: Cascade Training in Integrated
Area
• Concern trains DHMT on modules
• DHMT trains HF staff (quarterly)
• HF staff train CHWs (monthly)

10. Operations Research Results:
Knowledge and Practices
Indicator Type Example of Indicators Collected Total # % ‘non-
inferior’
Knowledge
 Danger signs in sick children
 Critical times for hand-washing
 Breastfeeding and complementary feeding practices
 Food groups and components of balanced diet
13 85%
Preventive
Practices
 Iron supplementation during pregnancy
 Immediate and exclusive breastfeeding
 Complementary feeding practices
 Hand-washing
 ITN use
13 100%
Sick Child
Practices
 Diarrhea: care-seeking, use of ORS, increased fluids and food
 Malaria: care-seeking within 24 hours, treatment with ACT
 Pneumonia: care-seeking and treatment with antibiotic
10 90%
Contact Intensity
 Contact with trained health information provider
 Attendance at community meetings where health of child was
discussed
4 100%
OVERALL 40 90%

11. Operations Research Results:
Functionality and Sustainability
% of CG meetings with at least 80% Volunteer attendance

12. Operations Research Results:
Functionality and Sustainability
% of HHs who received at least one visit by a CGV in the last month

13. Summary of Results
1. The Integrated Care Group model achieved at least the same improvements
in key knowledge and practices as the traditional model
2. The Integrated Care Group model functions as well as the traditional model
3. The Integrated Care Group model is as sustainable as the traditional model
 In at least the six month period following end of project support to CG
activities, project staff still active in area supporting other (non-Care
Group) project activities such as CCM
 Post-project sustainability study required

14. Learning
• CHWs are able to serve as Care
Group Promoters through a modified
model:
• No more than 2 CGs per CHW
• Monthly support (training and
supervision) from health facility
• Head nurses do not have time for Care
Group / CHW supervision – delegate to
a more junior nurse “focal point”
• Integrated Model allows for community
health data to be directly incorporated
into Ministry HIS

15. The ‘Value-Add’ of Integrated Care Groups
In addition to increasing potential for scale-up and sustainability,
Integrating Care Groups into the MOH structure:
 Capacity building of MOH staff at all levels
 Increase demand for CCM work by CHWs (identification and referral
of sick children during home visits)
 Reduction of workload of CHWs regarding the home visits
 Improved link between the health facility and the community

16. Policy Implications for Burundi MoH
Some issues to take in consideration:
 The start-up cost of Care Groups (Organization of CGV elections,
basic and refresher training of MOH staff, CHWs and CGVs)
 When national MOH should take the lead in training districts vs.
NGO staff
 The development and replication of the BCC modules, reporting
tools (during scale-up – when the MOH has not yet taken up the
approach fully)
 Integration of other community health activities in CG???

17. The Role of NGOs (medium term)
Key role of the NGO in the Integrated CG model:
 Support the district team for the start-up phase
 Capacity building of the district team
 Technical support to the district for the development of the
BCC modules and registers
 Financial support to the district team for the production of the
BCC modules and registers
 Advocacy at national level for the inclusion of the CG
approach in the national community health policy

18. What is Happening Now in Burundi?
 Integrated Care Groups from original program still
reporting to MOH and we are monitoring this data
 Concern has funding to scale-up Integrated Care Groups
in two additional districts (Ronald McDonald House
Charities and UNICEF)
 Extensive advocacy with MOH at national level to involve
them from the beginning in establishing Integrated Care
Groups (along with other Care Group implementers in
Burundi – World Relief, FH, IMC, CRS)

19. Conclusions
• Traditional Care Groups have been proven
to be effective in achieving coverage of key
health and nutrition behaviors in numerous
settings
• CHWs are a growing part of Ministry of
Health systems, however often difficult for
CHWs alone to attain complete household
coverage
• Integrated Care Group model holds
promise as a way to scale-up proven
practices at the household level while
leveraging existing structures, building local
capacity
Janvier Niandwi- Community Health Worker

20. Thank you!
For additional information:
Jennifer Weiss
Health Advisor
Concern Worldwide, US
Jennifer.weiss@concern.net
Delphin Sula
Health and Nutrition Program Manager
Concern Worldwide Burundi
delphin.sula@concern.net
www.concernusa.org