Please describe how your project has been successful and how that success is measured
Measuring impact is an important component of The Ihangane Project’s model for success. We emphasize the importance of building a system of monitoring and evaluation into each program. For this reason, we have set three main goals for the overall proposal that includes associated outcome objectives and timelines for completion. In addition, we have worked with the Ruli HIV Medical Team to implement a system of Monitoring & Evaluation into the clinical aspects of the program. This entire process has been guided by the direct involvement of representatives of all program stakeholders in Ruli, Rwanda.
In September 2010, TIP’s Infant Nutrition for HIV-Exposed Infants Pilot Project was successfully expanded to include all HIV-exposed infants between the ages of 6 and 24 months presenting at the Ruli District Hospital. Because of the high rate of death due to malnutrition amongst the infants whose mothers have died from any cause, the program has also been extended to any infant with malnutrition due to maternal death. Recent data shows that only 2 of the 41 children enrolled showed any evidence of under-nutrition, which is 7 times less than the average rate of malnutrition in this community. Because of the frequent nature of the nutritional assessments, these two children were quickly identified and referred to the malnutrition team for more concentrated support.
In 2010, the team developed a standard Infant Nutritional Assessment data sheet that would be completed for every program participant on a monthly basis. When the program expanded to include all eligible families at Ruli Health Center, the handwritten form was found to be cumbersome and less effective because of the labor-intense data entry into Excel spreadsheets. We are now in the process of developing an electronic version of the Infant Nutritional Assessment form. This will allow the medical staff to more easily follow the individual families over time, and also provide a simpler way to collect and review aggregate data. The team can more easily identify areas of strengths or weaknesses in the program, adjust the program according to this data, and then evaluate the impact of the changes.
To foster cross-training in both HIV and malnutrition, The Ihangane Project is developing a pocket guide that provides straightforward information regarding protocols for prenatal care, PMTCT, management of HIV-exposed infants, and the diagnosis/treatment of various forms of malnutrition. This guide will be distributed to all physicians, nurses, and health center staff to provide easy point-of-care access to most recent Ministry of Health protocols. It also provides commonly used formulas and charts to improve proper medication dosages for children. Because many nurses specialize in one particular area such as HIV or Malnutrition, these guides will begin to develop a bridge between disciplines and assist them in considering the entire spectrum of Maternal & Child health. In addition, decentralized health care has placed more responsibilities upon the nursing staff, while decreasing physicians’ involvement with outpatient medical care. The physicians find themselves faced with managing complex cases in the hospital without extensive outpatient experience in either HIV or malnutrition. These guides will provide direct access to information that saves time and promotes standard of care treatment for mothers and young children.
In May of 2011, a draft version of the Pregnant Women & Children Pocket Guide: HIV Prevention & Treatment was field tested with Rwandan physicians and nurses at Ruli District Hospital. Participants were universally were excited about the concept of this guide, and offered their feedback regarding additional information they would like included. A final version has been developed, and should be available for distribution in September of 2011.
One major challenge to food security is lack of access to farming inputs and farmable land. The Ministry of Health has advised all district-based malnutrition programs to organize families with children under 5 into farming groups. This would allow these families to share land, as well as seeds and other farming tools. Although excellent in concept, this has been difficult to implement due to lack of local resources. The Ihangane Project will work in collaboration with a hospital-based agronomist and Rwanda Economic Development Initiative (REDI) to create the most effective means of organizing these families to provide them with land, seeds, appropriate soil, and adequate knowledge in organic farming techniques. By taking this community-wide approach, HIV + families would be integrated into these farming cooperatives without being identified as HIV+. These farming cooperatives will provide access to a variety of nutritious foods, as well as income generation.
The NHI Program utilizes fortified sosoma as a staple nutritional supplement to prevent malnutrition amongst HIV-exposed infants. To improve long term sustainability of this aspect of the program, Ihangane Project would like to develop a mechanism for local fortified sosoma production. With the assistance of a 2010 William Davidson Institute Global Impact (WDI) fellow, TIP and the Ruli community developed several potential business models for local production of sosoma. For any model to be successful, local cultivation of soya, sorghum, and maize (components of SoSoMa) must be increased. Our goal is to encourage the farming cooperatives to cultivate these grains in enough quantity to produce sufficient sosoma supply for the hospital. The cooperatives would provide these grains in exchange for land provision and the initial start-up costs of the cooperatives.
In May of 2011, a large focus group was held with HIV+ families who receive their health care at Nyange Health Center. This community meeting led to a training session in sustainable agriculture that was conducted by WDI Intern Sean Morris. After this training session, the Nyange PLWHA Association presented Sean with a proposal for the development of a farming cooperative. He is working with this group to develop a list of expectations and a business plan that will include donation of soya and maize to the hospital in exchange for the start-up costs of this farming initiative. Once this agreement has been established, the Nyange PLWHA Association farming cooperative will serve as a pilot project for future health center based farming cooperatives.
With the assistance of WDI fellow Sean Morris and National University of Rwanda biostatistics student Huriro Uwacu Theophila, The Ihangane Project is working to better understanding the existing Community-Based Nutrition Program (CBNP) and identify areas of need through a system of comprehensive community-based surveys. The team has developed and conducted surveys for 100 community nutrition workers (CNWs) to assess a wide variety of parameters, including nutrition knowledge, job satisfaction and areas in need of improvement. A second survey, developed for CBNP participants, assesses topics such as satisfaction with the program, household resources, family size, family income and nutrition knowledge. These surveys have been widely distributed and collected throughout the catchment area of Ruli District Hospital, and the information gathered will guide our decisions regarding cost-effective interventions. In addition, this information will serve as baseline data by which we will measure the impact of our future interventions. Sean and Theo plan to present their findings and recommendations to the Ruli District Hospital Nutrition team managers in early August 2011. Based upon their feedback, TIP will work with the team to identify the next steps in implementation of these recommendations.
Preliminary review of this data shows that the program is in need of a standard nutrition education curriculum, as well as a system for ongoing education of the CNWs. There is a lack of access to practical teaching gardens, and many families lack access to land, soil, or seeds that are needed to develop kitchen gardens. Many of these issues can be addressed in a simple, cost-effective manner, and all stakeholders agree that a hospital-based agronomist would easily facilitate any interventions that are recommended. Once the appropriate interventions are identified and implemented, HIV+ families from our NHI Program will be integrated into this system to receive the benefits of appropriate nutrition education, household nutrition assessments, and training for the development of kitchen gardens.