Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar.

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all.

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

CMA analysis identifies homozygous deletion of MCPH1 in 2 brothers with primary Microcephaly-1.

BACKGROUND: Homozygous mutations and deletions of the microcephalin gene (MCPH1; OMIM *607117) have been identified as a cause of autosomal recessive primary microcephaly and intellectual disability (MIM #251200). Previous studies in families of Asian descent suggest that the severity of the phenotype may vary based on the extent of the genomic alteration. We report chromosome microarray (CMA) findings and the first described family study of a patient with primary microcephaly in a consanguineous Hispanic family. CASE PRESENTATION: The proband, a boy born at full-term to consanguineous parents from Mexico, presented at 35 months of age with microcephaly, abnormal brain MRI findings, underdeveloped right lung, almond-shaped eyes, epicanthal folds, bilateral esotropia, low hairline, large ears, smooth philtrum, thin upper lip, and developmental delay. MRI of the brain showed a small dermoid or lipoma (without mass effect) within the interpeduncular cistern and prominent arachnoid granulation. The underdeveloped right lung was managed with long-acting inhaled corticosteroids. Otherwise the proband did not have any other significant medical history. The proband had 2 older brothers, ages 14 and 16, from the same consanguineous parents. The 14-year-old brother had a phenotype similar to that of the proband, while both parents and the oldest brother did not have the same phenotypic findings as the proband. The SNP-based CMA analysis of the proband detected a homozygous 250-kb microdeletion at 8p23.2p23.1, extending from 6,061,169 to 6,310,738 bp [hg19]. This genomic alteration encompasses the first 8 exons of MCPH1. Follow-up studies detected the same homozygous deletion in the affected brother, segregating with microcephaly and intellectual disability. Regions of homozygosity (ROHs) were also observed in the affected brother. Since ROHs are associated with an increased risk for recessive disorders, presence of ROH may also contribute to the phenotype of the affected brothers. The parents were both hemizygous for the deletion. CONCLUSION: Here we report a homozygous deletion of multiple exons of the MCPH1 gene that was associated with primary microcephaly and intellectual disability in a Hispanic family. In the context of previous studies, our results support the idea that deletions involving multiple exons cause a more severe phenotype than point mutations.

Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era.

BACKGROUND: Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies. DISCUSSION: In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, "learning for leverage," NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, "thought leadership," NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, "joint venturing," NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts. CONCLUSION: With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.

Care Groups I: An Innovative Community-Based Strategy for Improving Maternal, Neonatal, and Child Health in Resource-Constrained Settings.

In view of the slow progress being made in reducing maternal and child mortality in many priority countries, new approaches are urgently needed that can be applied in settings with weak health systems and a scarcity of human resources for health. The Care Group approach uses facilitators, who are a lower-level cadre of paid workers, to work with groups of 12 or so volunteers (the Care Group), and each volunteer is responsible for 10-15 households. The volunteers share messages with the mothers of the households to promote important health behaviors and to use key health services. The Care Groups create a multiplying effect, reaching all households in a community at low cost. This article describes the Care Group approach in more detail, its history, and current NGO experience with implementing the approach across more than 28 countries. A companion article also published in this journal summarizes the evidence on the effectiveness of the Care Group approach. An estimated 1.3 million households­almost entirely in rural areas­have been reached using Care Groups, and at least 106,000 volunteers have been trained. The NGOs with experience implementing Care Groups have achieved high population coverage of key health interventions proven to reduce maternal and child deaths. Some of the essential criteria in applying the Care Group approach include: peer-to-peer health promotion (between mothers), selection of volunteers by mothers, limited workload for the volunteers, limited number of volunteers per Care Group, frequent contact between the volunteers and mothers, use of visual teaching tools and participatory behavior change methods, and regular supervision of volunteers. Incorporating Care Groups into ministries of health would help sustain the approach, which would require creating posts for facilitators as well as supervisors. Although not widely known about outside the NGO child survival and food security networks, the Care Group approach deserves broader recognition as a promising alternative to current strategies for delivering key health interventions to remote and underserved communities.

Care Groups II: A Summary of the Child Survival Outcomes Achieved Using Volunteer Community Health Workers in Resource-Constrained Settings.

The Care Group approach, described in detail in a companion paper in this journal, uses volunteers to convey health promotion messages to their neighbors. This article summarizes the available evidence on the effectiveness of the Care Group approach, drawing on articles published in the peer-reviewed literature as well as data from unpublished but publicly available project evaluations and summary analyses of these evaluations. When implemented by strong international NGOs with adequate funding, Care Groups have been remarkably effective in increasing population coverage of key child survival interventions. There is strong evidence that Care Groups can reduce childhood undernutrition and reduce the prevalence of diarrhea. Finally, evidence from multiple sources, comprising independent assessments of mortality impact, vital events collected by Care Group Volunteers themselves, and analyses using the Lives Saved Tool (LiST), that Care Groups are effective in reducing under-5 mortality. For example, the average decline in under-5 mortality, estimated using LiST, among 8 Care Group projects was 32%. In comparison, among 12 non-Care Group child survival projects, the under-5 mortality declined, on average, by an estimated 11%. Care Group projects cost in the range of US$3-$8 per beneficiary per year. The cost per life saved is in the range of $441-$3,773, and the cost per disability-adjusted life year (DALY) averted is in the range of $15-$126. The Care Group approach, when implemented as described, appears to be highly cost-effective based on internationally accepted criteria. Care Groups represent an important and promising innovative, low-cost approach to increasing the coverage of key child survival interventions in high-mortality, resource-constrained settings. Next steps include further specifying the adjustments needed in government health systems to successfully incorporate the Care Group approach, testing the feasibility of these adjustments and of the effectiveness of Care Groups in pilot programs in government health systems, and finally assessing effectiveness at scale under routine field conditions in government health programs.

A causal loop analysis of the sustainability of integrated community case management in Rwanda.

Expansion of community health services in Rwanda has come with the national scale up of integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhea. We used a sustainability assessment framework as part of a large-scale project evaluation to identify factors affecting iCCM sustainability (2011). We then (2012) used causal-loop analysis to identify systems determinants of iCCM sustainability from a national systems perspective. This allows us to develop three high-probability future scenarios putting the achievements of community health at risk, and to recommend mitigating strategies. Our causal loop diagram highlights both balancing and reinforcing loops of cause and effect in the national iCCM system. Financial, political and technical scenarios carry high probability for threatening the sustainability through: (1) reduction in performance-based financing resources, (2) political shocks and erosion of political commitment for community health, and (3) insufficient progress in resolving district health systems--"building blocks"--performance gaps. In a complex health system, the consequences of choices may be delayed and hard to predict precisely. Causal loop analysis and scenario mapping make explicit complex cause-and-effects relationships and high probability risks, which need to be anticipated and mitigated.

Plausible role for CHW peer support groups in increasing care-seeking in an integrated community case management project in Rwanda: a mixed methods evaluation.

BACKGROUND: The Kabeho Mwana project (2006-2011) supported the Rwanda Ministry of Health (MOH) in scaling up integrated community case management (iCCM) of childhood illness in 6 of Rwanda's 30 districts. The project trained and equipped community health workers (CHWs) according to national guidelines. In project districts, Kabeho Mwana staff also trained CHWs to conduct household-level health promotion and established supervision and reporting mechanisms through CHW peer support groups (PSGs) and quality improvement systems. METHODS: The 2005 and 2010 Demographic and Health Surveys were re-analyzed to evaluate how project and non-project districts differed in terms of care-seeking for fever, diarrhea, and acute respiratory infection symptoms and related indicators. We developed a logit regression model, controlling for the timing of the first CHW training, with the district included as a fixed categorical effect. We also analyzed qualitative data from the final evaluation to examine factors that may have contributed to improved outcomes. RESULTS: While there was notable improvement in care-seeking across all districts, care-seeking from any provider for each of the 3 conditions, and for all 3 combined, increased significantly more in the project districts. CHWs contributed a larger percentage of consultations in project districts (27%) than in non-project districts (12%). Qualitative data suggested that the PSG model was a valuable sub-level of CHW organization associated with improved CHW performance, supervision, and social capital. CONCLUSIONS: The iCCM model implemented by Kabeho Mwana resulted in greater improvements in care-seeking than those seen in the rest of the country. Intensive monitoring, collaborative supervision, community mobilization, and CHW PSGs contributed to this success. The PSGs were a unique contribution of the project, playing a critical role in improving care-seeking in project districts. Effective implementation of iCCM should therefore include CHW management and social support mechanisms. Finally, re-analysis of national survey data improved evaluation findings by providing impact estimates.

Providing community-based health practitioners with timely and accurate discharge medicines information.

BACKGROUND: Accurate and timely medication information at the point of discharge is essential for continuity of care. There are scarce data on the clinical significance if poor quality medicines information is passed to the next episode of care. This study aimed to compare the number and clinical significance of medication errors and omission in discharge medicines information, and the timeliness of delivery of this information to community-based health practitioners, between the existing Hospital Discharge Summary (HDS) and a pharmacist prepared Medicines Information Transfer Fax (MITF). METHOD: The study used a sample of 80 hospital patients who were at high risk of medication misadventure, and who had a MITF completed in the study period June - October 2009 at a tertiary referral hospital. The medicines information in participating patients' MITFs was validated against their Discharge Prescriptions (DP). Medicines information in each patient's HDS was then compared with their validated MITF. An expert clinical panel reviewed identified medication errors and omissions to determine their clinical significance. The time between patient discharge and the dispatching of the MITF and the HDS to each patient's community-based practitioners was calculated from hospital records. RESULTS: DPs for 77 of the 80 patients were available for comparison with their MITFs. Medicines information in 71 (92%) of the MITFs matched that of the DP. Comparison of the HDS against the MITF revealed that no HDS was prepared for 16 (21%) patients. Of the remaining 61 patients; 33 (54%), had required medications omitted and 38 (62%) had medication errors in their HDS. The Clinical Panel rated the significance of errors or omissions for 70 patients (16 with no HDS prepared and 54 who's HDS was inconsistent with the validated MITF). In 17 patients the error or omission was rated as insignificant to minor; 23 minor to moderate; 24 moderate to major and 6 major to catastrophic. 28 (35%) patients had their HDS dispatched to their community-based practitioners within 48 hours post discharge compared to 80 (100%) of MITFs. CONCLUSION: The MITF is an effective approach for the timely delivery of accurate discharge medicines information to community-based practitioners responsible for the patient's ongoing care.

Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique.

BACKGROUND: There is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement. METHODS: Using results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project's technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003. RESULTS: The project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively. CONCLUSIONS: LiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.