The Learning Collaborative on Child Health in Rwanda

Overview

A Learning Collaborative brings together healthcare organizations in an effort to improve care for a designated condition. As part of its mission to link research and action, the FXB Center’s Learning Group 3 (LG3) team launched a Learning Collaborative project with the Rwandan government in July 2007. The Learning Collaborative was initiated to increase the number of women receiving comprehensive prevention of mother-to-child transmission of HIV (PMTCT) services at the health center level in the Eastern Province of Rwanda. Seventeen health centers, supported by various non-governmental organizations, participated in the Learning Collaborative in order to promote the rapid dissemination and implementation of effective strategies for the delivery of PMTCT services within a community context.

Target objectives for the collaborative were established by the Rwandan Treatment and Research AIDS Center (TRAC) and Ministry of Health.

• 90% of all women in the district will have access to prenatal/PMTCT services
• 95% of women identified with HIV will be started on an ARV regimen in accordance with TRAC guidelines
• 95% of infants at risk for transmission of HIV will be supported with feeding method that will reduce the risk of HIV transmission through feeding
• 95% of all infants needing co-trimaxazole prophylaxis will receive medication
• 95% of all infants identified will use bed nets for malaria prophylaxis
• 95% of infants identified will receive three visits in 6 months to ensure appropriate early childhood development
• 95% of all infants will have access to full immunization programs

Methods

The organization and activities of the Learning Collaborative are based on the Institute for Healthcare Improvement (IHI)’s “Breakthrough Series” model. Participating health centers in Rwanda attended periodic meetings, called Learning Sessions, where they examined proven and recommended strategies for improving care for children affected by HIV/AIDS and developed plans for incorporating such strategies within their organizations. Between the learning sessions, members will be engaged in Action Periods where they learn from testing different changes within the current system and sharing their learning across teams to more rapidly implement successful strategies.

Four intermittent learning sessions were scheduled throughout the project. At Learning Session One, health center staff, their hospital affiliates, and district supervisors discussed collaborative objectives, best practice standards, and national guidelines. Health center staff received training in the Breakthrough Series methodology of “Plan-Do-Study-Act” cycles (PDSAs), in which problems are identified, solutions tested, results analyzed, and improvements incorporated into standard working procedures. Following this learning session, a small team trained in the collaborative method visited each health center a minimum of twice monthly to assist staff with PDSAs and improvements toward collaborative objectives. The second and third learning sessions facilitated the sharing of progress and findings among health center staff and prepared them for the scale up of successful interventions in subsequent action periods.

Learning Session Four was held at the end of the Learning Collaborative and was an opportunity for all participants to share lessons learned, final results, and policy implications for national PMTCT service delivery.

Early Childhood Development

Early Childhood Development (ECD) was considered an essential component of comprehensive PMTCT care. Through visits to the health centers, it was observed that growth monitoring consisted of weight and height measurements to screen for malnutrition, but ECD monitoring for linguistic, social and physical development was not practiced. An ECD tool was designed using the WHO Integrated Management for Childhood Illness (IMCI) module on Care for Development. This tool is intended for use by Community Health Workers (CHWs) during home visits to conduct simple developmental screening and provide counseling to the mother on ways to play and communicate with her child to encourage healthy growth and development.

An activity based training module was developed to help nurses carry out interactive role-play, discussions and demonstrations to teach CHWs how to conduct ECD monitoring. Nurses at all participating health centers received training on ECD in November 2008. In the following months, nurses used the training module to train CHWs how to use the ECD tool during home based consultations.

The Learning Collaborative will gather feedback from CHWs on their experiences using the ECD tool, the information they have retained from training sessions, and mothers’ responses to counseling provided. This information will be essential in formulating recommendations for the MOH on incorporating ECD material in the national CHW training curriculum.

Preliminary Findings

The Learning Collaborative team at the FXB Center is currently evaluating and preparing final results for publication; preliminary results suggest several observations. Availability and quality of PMTCT and child health services varied across participating health centers, depending on support received from their partnering non-government organizations. Loss to follow-up after initial antenatal services posed a significant barrier to service delivery, preventing appropriate PMTCT care from starting at 28 weeks of pregnancy. At some health centers, up to one half of HIV-positive women did not return for further care. All health centers reported less than 10% of women completing four antenatal visits. All health centers were able to successfully utilize the PDSA approach to implement effective, low- or no-cost solutions to increase provision of PMTCT services. Health centers documented increases in the number of women receiving PMTCT services, antenatal services, and children receiving follow up care, including immunizations and bed nets for malaria prevention. Results thus far show that first trimester antenatal attendance has increased by 78%, overall antenatal attendance has increased by 42%, Bactrim provision for children remains above 96%, and immunization rates and bed net distribution have both increased by more than 10% since the start of the Learning Collaborative.

While there were significant challenges in applying the Breakthrough Series PDSA cycles process, the Learning Collaborative proved beneficial on several levels. Participating health centers identified effective, low-, or no-cost solutions to longstanding PMTCT problems, and have begun to improve the delivery of related child services. These improvements in services include, for example, increasing access to antenatal services, ensuring the delivery of anti-retroviral medications, improving feeding counseling and infant follow-up — as well as improvements in increasing vaccination and bed net coverage, and early childhood development monitoring. More generally, the early Learning Collaborative results demonstrate that the Breakthrough Series model may be applicable for addressing service delivery problems in low-resource settings. Once results are complete, procedures that were most effective may be mainstreamed at a national level, as tools for governments that face similar challenges.