CASE STUDY: FOOD FOR THE HUNGRY'S CARE GROUP PROGRAM, LOCATION: SOFALA, MOZAMBIQUE

Improving Child Health and Nutrition with Care Group Programs: Cost Impact Profile

Cost per impact:
  • Cost per child life saved: ~$440
Average cost:
  • ~$3 per direct beneficiary (mothers and young children) per year

Representative Impacts and Outcomes:
Estimated: 5,500 child lives saved, 30% decrease in under-five mortality over five years, 38% decline in incidence of moderate and severe undernutrition

Care Group Programs: Improving Child Health and Nutrition

Care Groups are peer-based health promotion programs that can quickly and effectively improve health behaviors and outcomes in low-resource communities. In empowering mothers and local leaders, the Care Group model demonstrates that high-impact solutions to childhood malnutrition and illness can be simple, low-cost, and community-derived.

Nutrition 101
FAST FACTS:
  • Globally, one in four children is malnourished.
  • Malnutrition contributes to 35% of under-five child deaths annually.
  • On average, only 35% of children under six months of age are exclusively breastfed, and few children receive appropriate complementary foods.
  • Optimal breastfeeding and complementary feeding practices can save the lives of 1.5 million children every year.

Today, undernutrition is the single largest contributor to childhood illness and death.1 Affecting nearly one in four children worldwide, malnutrition is frequently accompanied by infectious disease, physical disability, and developmental delay.2 Improper nutrition and feeding practices during the first two years of life can cause irreversible damage, permanently affecting a child’s ability to learn, to grow, and to provide for his or her family in the future.

There are a number of maternal behaviors that are proven to reduce childhood malnutrition and death in resource-poor communities. For example, breastfeeding, appropriate complementary feeding, and water and sanitation behaviors contribute to improved nutritional status and the prevention of pneumonia, diarrhea, and neonatal infection in young children.3 The landmark Lancet series on maternal and child nutrition also found that breastfeeding and food supplementation programs resulted in decreased risk of death, increased growth, and fewer years lived with disability for children under the age of five.4

Despite the proven success of these simple behaviors, they are often not practiced by mothers, and proven methods to effectively promote them at low cost in large populations are scarce. For instance, in Mozambique, the national rate of exclusive breastfeeding for children under six months is less than 40%.5 The primary challenge is to overcome social barriers and to provide health promotion at low cost for mothers of young children. Engaging community-derived resources and mobilizing large numbers of women as volunteers, the Care Group model facilitates peer-to-peer behavior change in developing countries.

What is a Care Group?

The Care Group model involves NGO staff, paid health promoters, volunteer women, and beneficiary mothers.

  • Individuals are first selected from the community to be paid health promoters. The promoters are taught essential practices for good hygiene and infant care by the NGO.
  • Each health promoter is then tasked with forming 5-10 Care Groups. Each Care Group will have between 10-16 volunteer women (many of whom are mothers) who are selected either by the mothers that they will serve or by community leaders. This process helps to assure that many of the volunteers are “hubs” in their respective social networks, and therefore better positioned to persuade their neighbors to adopt new health behaviors.
  • Every two weeks, the Care Group meets with the health promoter to learn a new set of nutrition- or health-related messages and activities. The health and nutrition messages are often based on “Barrier Analysis” studies that identify key enablers and barriers to the implementation of a behavior in resource-poor communities. After each Care Group meeting, each volunteer woman is responsible for sharing this information with 10-15 beneficiary mothers in her respective neighborhood.
  • The Care Group structure also strengthens the local health information system by collecting information on the health practices of mothers and children in the area, and builds better connections between communities and local health facilities.
  • With this method, if one health promoter creates just five Care Groups, he or she can reach more than 1,000 families with lifesaving information.6 This system builds upon the strength of pre-existing community ties and trust, along with guidance from the NGO, in order to saturate a community with vital health-related knowledge. The model also ensures that every household with a young child or pregnant woman within a target community is reached.

Program Goals

  • Reduction in morbidity and mortality rates, especially among young children
  • Increase in demand for community health services
  • Transfer of knowledge and skills necessary for effective and lasting community health development in order to ensure the continuation of preventative measures in the aftermath of the program7
Case Study: Food for the Hungry’s Mozambique Child Survival Program

Food for the Hungry (FH) is a faith-based international relief and development organization with programs in more than 25 countries. Since 1987, FH has worked in the Sofala province of Mozambique, focusing primarily on health, agriculture, and savings initiatives.8

Population:

  • The Child Survival Program took place in seven districts in the Sofala Province of Central Mozambique.
  • Reaching a population of 1.2 million, the intervention primarily targeted pregnant women and mothers with children 0-23 months.
  • At the start of the program, Mozambique had one of the highest under-five mortality rates in the world, at 153 deaths per 1,000 live births.9
  • The rural region of Sofala was characterized by a lack of health care infrastructure: high rates of illiteracy, entrenched traditional beliefs, and a lack of modern medical services were seen as barriers to care and health information.10

About the Program:

  • The Child Survival Program, funded in part by USAID, took place between October 2005 and September 2010.
  • Each Care Group, made up of 12 volunteer women, would meet on a biweekly basis with the NGO’s paid health promoter for lessons on health, hygiene, and care. On top of learning new material, the groups would also review the previous lesson. Each Care Group member was then responsible for meeting and sharing information with her cohort of 12 beneficiary mothers, using a combination of group meetings and home visits.
  • Health promotion messages focused primarily on nutrition (exclusive breastfeeding for the first six months, appropriate complementary feeding), but also on water treatment, sanitation and hygiene, danger signs during pregnancy and among young children, preventative care (immunizations and prenatal care), and safe birthing practices.11
  • The goal of the program was to connect with every pregnant woman and mother in the target region in order to promote health behaviors with her and those who influence her (e.g., husbands, grandmothers). By providing health information in a culturally sensitive way, the program aimed for rapid behavior change and measurable improvements in child survival and nutrition.12

Representative Impacts

Over a five-year period, Food for the Hungry’s Care Group program in Sofala, Mozambique reduced under-five mortality by 30% and reduced child malnutrition by 38%.13

  • Using the Lives Saved Tool (LiST), it was estimated that the project saved ~5,500 lives (4,590-6,848)14 of children under the age of five.
  • Rapid changes in health behaviors: Exclusive breastfeeding to six months more than doubled, hand washing increased 50 percentage points, ORS preparation for diarrhea treatment increased by 41 percentage points and the number of mothers who could recognize three or more signs of childhood illness tripled.

Results of Care Groups in Central Mozambique between 2005-201015,16

The positive impacts of Care Groups have been observed by other organizations implementing this approach.

  • World Relief’s child survival program implemented Care Groups in Gaza, Mozambique between 2000-2003 and was able to achieve substantial improvements in health-related behaviors, such as high coverage for bed net use (80%), oral rehydration therapy for children with diarrhea (94%) and successful evaluation and care-seeking for children with danger signs of severe illness.17 The region also saw a 66% decrease in infant mortality and a 62% decrease in under-five child mortality (see our Malaria Guide for more information).
  • A World Relief child survival program implemented in the Kampong Cham Province of Cambodia saw a rapid increase in child survival behaviors using the Care Group approach. The initiative saw a decline in the under-five mortality rate- from 129 to 35 deaths per 1,000 live births in just five years,18 and its projected total cost was less than $2 per capita per year.19

Additional Impacts

  • Care Group volunteer mothers are empowered – Surveyed volunteers reported significant respect from others in their social networks as a result of participation in the project. All of the mothers noted that they were more respected by other women in their community because of their participation as a Care Group volunteer. Of the volunteers, 64% reported being more respected by community leaders, and 61% reported being more respected by their husbands.20

Sustainability

  • According to surveys conducted by World Relief at 30 and 45 months after the end of their Care Group project in Mozambique (outside training and funding ceased), final program goals on eight key indicators continued to be exceeded. Many communities had continued selecting and training new volunteers on their own. 93% of volunteers were still active 20 months after the formal project ended.21

Program Costs and Cost/Impact Profile

Program Costs

The annual cost per direct beneficiary (mother with young child) per year was ~$3

The annual cost per capita (among the entire population) per year was ~$0.50

  • The total program cost for all seven districts was $3,024,166
  • The program spanned five years, from October 2005 to September 2010
  • There were 219,617 direct beneficiaries and 1.2 million total individuals in the target population

Cost/Impact Profile

Disability-Adjusted Life Year, or DALY, combines both survival and disability into one metric.

One DALY is equal to a year of healthy life lost due to a health problem. It is used to quantify the burden of disease from specific causes in different regions, to calculate the cost-effectiveness of interventions, and to estimate the impact of actual public health programs.

Estimated cost per life saved ~$440-$660

Cost per DALY averted ~$15-$22

For the Number Crunchers:

  • Average cost per life saved=Total program cost/Total lives saved
  • Utilizing the uncorrected estimate of 6,848 lives saved, the average cost per life saved was $440 ($3,024,166/6,848=$441). The cost per Disability-Adjusted Life Year, or DALY22, averted was ~$15 (in the “highly attractive cost-effectiveness” range promoted by the World Bank23 )
  • In considering what improvements in health might have happened without the program and utilizing the more conservative estimate of 4,590 lives saved, the cost per life saved was around $660. ($3,024,166/4,590=$660). The cost per DALY averted was ~$22.

The Care Group model has been replicated by a number of other NGOs and programs with great health impact at low cost. A review of eight Care Group projects by USAID in 2008 found the following outcomes:24

  • 26%-48% reduction in under-five mortality
  • Average cost was between ~$3-$8 per beneficiary
  • Cost per life saved was between ~$400-$3,700
Taking Action: Donor Tools and Resources
CARE GROUPS: MAJOR TAKEAWAYS

  1. Care Groups utilize a peer-based health promotion model that saturates a community with critical health information. Care Groups can quickly and effectively promote positive change.
  2. By engaging local mothers and leaders as volunteers, a Care Group enables community members to address their own health problems at a low cost.
  3. Care Groups demonstrate that high-impact, low-cost solutions to decreasing child mortality and disability can be simple and community-derived.


For more information about the Care Group Model, visit caregroupinfo.org or contact Sarah Borger at sborger@fh.org. For information on evidence and results of Care Groups, please visit www.caregroupinfo.org/blog/results.

Additional Nonprofits Using the Care Group Model

Food for the Hungry is just one organization utilizing the Care Group model. Care Groups are currently being implemented by at least 24 non-profit organizations in 21 countries. You can find links to Food for the Hungry, Core Group, World Relief, and many other groups that are using the Care Group model at caregroupinfo.org/blog/implementors.

Tips for Assessing Care Group Health and Nutrition Projects

The points below can serve as a quick reference guide in assessing whether or not programs incorporate the Care Group model. It is based on the Care Group Minimum Criteria Reviewer Checklist, which can be downloaded here.

The program focuses on community-based, peer-to-peer health promotion, with the goal of empowering local women and saturating a region with vital health information.

The program’s volunteers are recommended or chosen by mothers in the neighborhoods that they will serve in, ensuring that they will be respected and effective communicators. Volunteers receive no cash incentives.

All of the volunteer mothers live within reasonable distance of the households that they serve, which allows them to make regular visits to each household.

The organization implementing the program supervises and trains health promoters to ensure that beneficiary mothers are receiving sound information on a regular basis.

The program uses data from the community that it is working with to construct and to revise goals so that it addresses the needs of the target population.

Additional Opportunities for Entrepreneurial Donors

The Care Group model can serve as a platform for a range of entrepreneurial ventures. For example, Care Group models can be used to:

  • Bring job training and microenterprise to women already served by Care Group programs
  • Educate women involved in the Care Group program about agriculture-nutrition linkages through the Care Group model

Donors can support pilot studies examining the potential of Care Groups to address other household-level behaviors through peer networks.

  • Some current areas of interest include child education (communicating the value to parents), maternal depression, deworming for parasitic infections, and savings.
  • There is also a need to test out the approach in other influential peer networks including groups of men and grandmothers.

*See references.