Theory of Change

Comprehensive Evaluation of the Community Health Program in Rwanda

© Concern Worldwide

1. Program Theory of Change© Concern Worldwide

Inputs

Activities

Outputs

IntermediateOutcomes

Impact

Funding Technicalassistance Coordination Partnership

CoverageofANC,SBAand

PNC

1ASMand2Binomes deployedineachvillageanddeliveringadefinedcommunityhealthpackage

ofpromotive,preventiveandcurativeservices

Immunizationcoverage

TreatmentofARI,malariaanddiarrhoea

IYCF

Maternalhealth NewbornandU5mortality

Infantandyoungchildnutrition

Immediateoutcomes Increasedaccessto/utilizationof

essentialinterventions

Improvedkeyhouseholdpractices

Leadership

Review/designofpolicies,plans,protocols,andguidelines CoordinationandManagement

Resourcesmobilization

Motivationandretention

(C-PBFandCHWs’Cooperatives)

FamilyPlanning

Hygieneandnutritionpractices

Increased,equitablecoverageofanessentialpackageofinterventionsalongthecontinuumofcare

Planning

Careseekingbehavioursathouseholdlevel

SexualandReproductiveHealth

DecreasedprevalenceofHIV/AIDS,TBand

malaria

HumanResources

RecruitmentofCHWs

TrainingofCHWs

Supplyofdrugs,equipmentandconsumables

Supervision/mentorshipof

CHWs

MonitoringandEvaluation

Reporting

1ASM 2BinomesMNHCBPFPHealth promotion

iCCMCBPFPNutritionHealth promotionTBDOTs

Timelydetectionandreferralforpreventiveandcurativeservices Communityengagedinplanning

communityhealthandinassessinglocalhealthneed

TBcureanddetectionrates

2. Key Assumptions© Concern Worldwide

Keyassumptions.Institutionalcapacitytodeploysufficient,skilledhealthcaremanagerstooverseeandcoordinatetheCHP

.Institutionalcapacitytodeploysufficient,skilledhealthcareworkersinchargeofdirectsupervisionofCHWsatDistrictandFacilitylevel

.SufficientvolunteersatcommunitylevelmeetingminimumrequirementstobeenrolledasCHWs

.SufficientmeansinplacetoallowmanagersandhealthcareworkerstocoordinateandsupervisetheCHP

.CoordinatedapproachtoprocurementofequipmentandmedicalsuppliesforCHP

Keyassumptions.Planning,managementandsupervisionstrategyandtoolsinplaceandconsistentlyadoptedinallsites

.TechnicalassistanceprovidedtosetupandimplementalltheCHPactivitiesatalllevelsandinallsites

.Clearcoordinatingstructureconsistentlyinplaceatalllevels

.Policies,protocolsandguidelinesforCHPinternallyconsistent,availableatalllevelsandupdated

.Localsupportfrompartnersconsistentwithplansandneeds

FromInputstoActivities

Keyassumptions.HighlevelpoliticalcommitmenttodeliverCHPatscale

.DonorsandpartnerscommitmenttosupportCHP

.FundingfromdonorsiscatalytictoleveragelocalresourcesforCHP

.RelevantlineMinistries(MINALOC,MINECOFIN,MOH)planincoordinationatalllevels

Funding Technicalassistance CoordinationPartnershipLeadershipHumanResources

andmeans

Review/designofpolicies,plans,protocols,andguidelinesCoordinationandManagement

Resourcesmobilizationatcentralandlocallevel

MotivationviaCooperatives

Planning

RecruitmentofCHWs

TrainingofCHWs

Supplyofdrugs,equipmentandconsumables

Supervision/mentorshipof

CHWs

MonitoringandEvaluation Reporting

Inputs

Activities

Assumptions

SupervisionandReporting.SufficientHRHinplacetoallowforregular,qualitysupervision.Supervisionguidelinesandtoolsinplace.SupervisionimprovesCHWs’performance.Meansandresourcesavailabletoperformsupervisionatcellanddistrictlevel.Cellcoordinatorsandin-chargesatHFareskilledandmotivatedtoperformsupervision--------------------------------------------.Reportsareregularlyproducedatalllevels.Quality,accuracyandtimelinessofreportsoverseenandmanaged.Reportsinformdecisions.Feedbackmechanismsinplace

FromActivitiestoOutputs

Recruitmentandretention.CommunitieselectCHWsasneeded,andinrespectofminimumeligibilitycriteria

.3CHWsareregularlyinpostineachvillage

.FinancialincentivesandparticipationtocooperativesmotivateCHWstostayinpost

.CHWsmaintainarespectfulattitudeandbehavioursothattheyarenotreplacedbycommunities

.NewCHWsarerecruitedtimelyasneededtoreplacethosewholeavethepost

Outputs 1ASMand2Binomes deployedineachvillageanddeliveringadefinedcommunityhealthpackage

ofpromotive,preventiveandcurativeservices

Review/designofpolicies,plans,protocols,andguidelinesCoordinationandManagement

Resourcesmobilizationatcentralandlocallevel Planning

Recruitmentandretentionof

CHWs

TrainingofCHWs

Supplyofdrugs,equipmentandconsumables

Supervision/mentorshipof

CHWs

MonitoringandEvaluation

Reporting

Activities

Assumptions

Training.Trainingguidelines,curriculaandtoolsareinplaceforeachleveloftheCHPToT cascade.TherearesufficienttrainerstosupportToT fromcentraltodistrict,facilityandcommunitylevel.CHWstrainingimprovestheirknowledgeandpractice.AllCHWsreceivetrainingasperguidelines.Apolicyforrefreshertrainingisinplaceanditisimplemented.Fundingandmeansareinplacetosustaintraining.Partnerssupporttrainingcentrallyoratlocallevelinlinewithnationalguidelinesandasneeded

Supplyofequipmentanddrugs.ThereareclearguidelinesdefiningtheminimumequipmentforCHWsanditsreplacementpolicy.AlltheequipmentisprocuredanddistributedtoallnewCHWs.EquipmentisdulymaintainedandusedbyCHWs-------------------------------------------------.MedicinesareregularlyprocuredandavailabletoCHWs.HealthfacilitiesdistributemedicinestoCHWsasperguidelines.Quantificationofcommunityneedsisappropriate,anditismonitoredandreviewedatcell,facilityanddistrictlevel.Stockoutaretimelyreportedandaddressedviarapidreplenishment.Expiryofdrugsismonitoredandtimelyreported

Monitoringandevaluation.RoutinedatafromHMIS,Siscom andRapidSMSregularlycollectedatalllevels.Quality,timelinessandaccuracyofdataassessedandqualitycontrolmechanisminplace.SufficientskilledHRHatcentral,districtandfacilityleveltomanageroutinedata.Routinedataregularlyanalysedandcoreindicatorsusedfordecisionmakingandtoimproveperformance-----------------------------------------------.ACHPresearchagendainformsstudiesonCHPimplementedinRwanda.Allevidenceiscentrallycollected,updatedandusedbypolicymakers.EvaluationfunctiondefinedandregularevaluationsofCHPperformed

Keyassumptions.CommunitiesparticipatetotheelectionoftheirCHWs

.CHWsparticipatetocommunitylevelactivities(planning,campaigns,etc)

.Localleaders,traditionalauthoritiesandreligiousleaderssupportandpromotetheworkofCHWs

.Thereiscoordinationatcommunitylevelbetweencivilsocietyorganizations,communityvolunteersandothercadres

.Communitiesareengagedindefininghealthplansatlocallevel

Keyassumptions.CHWsregularlyperformallservicesasperCHPcurriculum

.CHWsregularlyaccesshouseholdstoofferservices

.QualityofCHWsservicesleadstotrustandacceptancefromcommunities

.CommunitiesperceiveclearadvantagesinseekingadviceorcarefromaCHWratherthanothersourcesofcare(privateprovider;formalhealthsystem)

.Communitiesdemandforservices

.AllcommunitiesaccessCHWsservices

FromOutputstoImmediateOutcomes

Keyassumptions.CHWsregularlyperformhealthpromotionactivities

.LocalleadersandotherinfluentialpeopleincommunitiessupportthehealthpromotiondeliveredbyCHWs

.HealthPromotionCampaignsorganizedbythehealthsectorsupportactivitiesperformedbyCHWs

.Communitiesaccesshealthpromotionservices

.Improvedknowledgeleadstochangeinpractices

Outputs1ASMand2Binomes deployedineachvillageanddeliveringa

definedcommunityhealthpackageofpromotive,preventiveandcurativeservices

Immediateoutcomes Increasedaccessto/utilizationof

essentialinterventions

Improvedkeyhouseholdpractices

Careseekingbehavioursathouseholdlevel

1ASM 2BinomesMNHCBPFPHealth promotion

iCCMCBPFPNutritionHealth promotionTBDOTs

Timelydetectionandreferralforpreventiveandcurativeservices Communityengagedinplanning

communityhealthandinassessinglocalhealthneed

Assumptions

Keyassumptions.Dangersignsrequiringimmediatecareareknownathouseholdlevel

.CHWsareabletodetectdangersignsandtoassesswhetherreferralisneeded

.CommunitiesknowtheirCHWsandareabletoreachthemquicklyatanytime,incaseofhealthemergencies

.CHWshaveregularaccesstoRapidSMS(phone;chargers;credit)

.RapidSMStriggersandimmediateresponsefromthehealthfacility

.Ambulanceservicesreadilyavailableifneeded