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in most <strong>of</strong> households, particularly for<br />
households in cluster B and C.<br />
Most households in cluster A were<br />
found to have been engaged in agricultural<br />
activities on their own land during<br />
the last rainy season where they cultivated<br />
mainly millet. Households in clusters B<br />
and C did not cultivate land which made<br />
these households dependent on food aid<br />
and on purchase <strong>of</strong> food from the local<br />
market.<br />
Cluster A households ate a wider variety<br />
<strong>of</strong> food items in the two weeks prior to<br />
conducting the interviews when<br />
compared to households in cluster B and<br />
C during the same period. In cluster A,<br />
food types consumed included cereals,<br />
sugar, cooking oil, dry and fresh meat,<br />
milk, biscuits, dry okra, fresh vegetables,<br />
and sometimes fruits. In comparison,<br />
households in clusters B and C were<br />
found to have rarely consumed fresh<br />
meat, vegetables and fruits.<br />
Children in cluster A were between the<br />
ages <strong>of</strong> 7-22 months and were found to<br />
have been fed more frequently i.e.<br />
between 3-4 times, when compared to<br />
children in clusters B and C who were fed<br />
between 2-3 times a day. Children in cluster<br />
B and C were mainly fed asida and<br />
poor quality molah made <strong>of</strong> dry meat, dry<br />
okra and kawal.<br />
Heads <strong>of</strong> households in cluster A were<br />
found to have more access to regular<br />
sources <strong>of</strong> income and were either receiving<br />
monthly salaries from regular<br />
employment or owned small business<br />
which provided regular sources <strong>of</strong> income<br />
all year as well as access to cultivation.<br />
The household heads <strong>of</strong> cluster B and C<br />
depended on seasonal employment<br />
opportunities. These household reported<br />
experiencing money shortage and subsequently<br />
food shortage frequently during<br />
the year.<br />
Water consumption/uses in all households<br />
seemed to be adequate. Differences<br />
between the three clusters were mainly in<br />
water uses/quality/hygiene. Observation<br />
<strong>of</strong> water containers, especially water<br />
jerkins, from all households in cluster A<br />
looked clean unlike most jerkins from<br />
cluster B and C.<br />
Interview results suggest that left-over<br />
food was not consumed by the targeted<br />
children in most <strong>of</strong> the cluster A households.<br />
The few households in cluster A<br />
which fed targeted children left-over,<br />
reported feeding children the leftover<br />
food only after reheating. They also<br />
reported food was consumed shortly after<br />
it was prepared/reheated. These ‘good’<br />
food handling practices were not prevalent<br />
in the other two clusters, where left<br />
over food was <strong>of</strong>ten fed to the targeted<br />
children.<br />
Mothers from all households in cluster<br />
A reported washing their hands with soap<br />
and water more frequently during the day,<br />
7-10 times, compared to mothers in clusters<br />
B and C who used to wash their hands<br />
only between 5-6 times. Soap consump-<br />
tion was reported to be more prevalent in<br />
households in cluster A than in households<br />
in clusters B and C.<br />
All children in cluster A where found<br />
not to have not experienced any illness<br />
such as diarrhea, vomiting, fever or<br />
common cold within the last 30 days prior<br />
to conducting <strong>of</strong> the interviews for <strong>this</strong><br />
study. On the other hand, all children<br />
included in Clusters B and C were sick<br />
with diarrhoea, vomiting and fever within<br />
the last 14 days prior to conducting <strong>of</strong> the<br />
interviews. Food consumption <strong>of</strong> children<br />
in these clusters during the illness period<br />
was described as very poor. Mother<br />
reported that these were children mainly<br />
dependent on breastfeeding during the<br />
bouts <strong>of</strong> illness. These findings were more<br />
evident in cluster C (severely malnourished<br />
children).<br />
Discussion and Recommendations<br />
Although the sample size <strong>of</strong> households<br />
included in <strong>this</strong> study was small and<br />
therefore, findings cannot be generalized<br />
to the larger population in Al-Salaam area<br />
or Kabkabyia town these findings are still<br />
useful for planning purposes.<br />
Findings suggest that agencies should<br />
consider job creation interventions, e.g.<br />
income generating activities, that would lift<br />
vulnerable populations out <strong>of</strong> poverty.<br />
Training on proper finance management at<br />
the household level should also be considered<br />
in an effort to change the noted culture<br />
<strong>of</strong> “I only need to look for work when there<br />
is no money or food in the house”.<br />
It is also important to look at the<br />
adequacy <strong>of</strong> food aid rations received by<br />
displaced people. The study finds a significant<br />
discrepancy between number <strong>of</strong><br />
people living in a household with the<br />
number registered on the ration card, so<br />
that the ration does not last as long as<br />
planned. The ongoing re-verification exercise<br />
<strong>of</strong> the IDPs in Darfur should help in<br />
addressing such discrepancies and should<br />
also assist WFP in determining which<br />
household are more vulnerable than<br />
others and therefore allow for provision <strong>of</strong><br />
food aid required accordingly.<br />
There is also a need for more education<br />
and awareness raising programmes<br />
around <strong>issue</strong>s <strong>of</strong> hygiene and sanitation,<br />
as well as more provision <strong>of</strong> soaps/detergents<br />
or water purifiers as necessary to the<br />
households.<br />
The <strong>issue</strong> <strong>of</strong> soap shortage in most <strong>of</strong><br />
the households with malnourished children<br />
should also be addressed. This can be<br />
done through increasing the soap ration<br />
received, which should be linked to the<br />
results <strong>of</strong> the proposed verification exercise<br />
in order to properly match the<br />
number <strong>of</strong> people actually living in the<br />
household with the number <strong>of</strong> soap bars<br />
to be received.<br />
There also needs to be awareness raising<br />
activities for mothers and child<br />
caregivers regarding symptoms and<br />
management <strong>of</strong> child malnutrition with an<br />
emphasis on child feeding practices.<br />
Effects <strong>of</strong> performance<br />
payments to health<br />
workers in Rwanda<br />
Summary <strong>of</strong> published research 1<br />
Research<br />
Astudy just published in the Lancet set out to assess<br />
the effect <strong>of</strong> performance-based payment <strong>of</strong><br />
healthcare providers on the use and quality <strong>of</strong><br />
child and maternal care services in healthcare facilities in<br />
Rwanda. Payment for performance (P4P) schemes<br />
provide financial incentives to healthcare providers for<br />
improvements in utilisation and quality <strong>of</strong> specific care<br />
indicators. They can affect the provision <strong>of</strong> heath care in<br />
two ways: by giving incentives for providers to put more<br />
effort into specific activities and by increasing the<br />
amount <strong>of</strong> resources available to finance the delivery <strong>of</strong><br />
services. However, P4P schemes can have a detrimental<br />
effect. For example, when P4P payments depend on<br />
completion <strong>of</strong> reports, providers might spend more time<br />
on administrative duties and less time ensuring that<br />
patients receive the best quality care. In <strong>this</strong> study, the<br />
researchers assessed the potential <strong>of</strong> a P4P scheme to<br />
increase use and quality <strong>of</strong> key maternal and child health<br />
services. The impact evaluation was done prospectively<br />
in parallel with the rollout <strong>of</strong> a national P4P programme<br />
in Rwanda.<br />
One hundred and sixty-six facilities were randomly<br />
assigned at the district level either to begin P4P funding<br />
between June 2006 and October 2006 (intervention<br />
group, n=80) or to continue with the traditional inputbased<br />
funding until 23 months after study baseline<br />
(control group, n=86). Randomisation was done by toss<br />
<strong>of</strong> a coin. The researchers surveyed facilities and 2,158<br />
households at baseline and after 23 months. The main<br />
outcome measures were prenatal care visits, institutional<br />
deliveries (births), quality <strong>of</strong> prenatal care, child preventive<br />
care visits and immunisation. The study team<br />
isolated the incentive effect from the resource effect by<br />
increasing comparison facilities’ input-based budgets by<br />
the average P4P payments made to the treatment facilities.<br />
The team estimated a multivariate regression<br />
specification <strong>of</strong> the difference-in-difference model, in<br />
which an individual’s outcome is regressed against a<br />
dummy variable, indicating whether the facility received<br />
P4P that year, a facility-fixed effect, a year indicator, and a<br />
series <strong>of</strong> individual and household characteristics.<br />
The model estimated that facilities in the intervention<br />
group had a 23% increase in the number <strong>of</strong> institutional<br />
deliveries and increases in the number <strong>of</strong> preventive care<br />
visits by children aged 23 months or younger (56%) and<br />
children aged between 24 months and 59 months<br />
(132%). No improvements were seen in the number <strong>of</strong><br />
women completing four prenatal care visits or <strong>of</strong> children<br />
receiving full immunisation schedules. The team<br />
also estimated an increase <strong>of</strong> 0.157 standard deviations<br />
(95% CI 0.026-0.289) in prenatal quality as measured by<br />
compliance with Rwandan prenatal care clinical practice<br />
guidelines. The P4P scheme in Rwanda had the greatest<br />
effect on those services that had the highest payment<br />
rates and needed the least effort from the service<br />
provider.<br />
Researchers concluded that P4P financial performance<br />
incentives can improve both the use and quality <strong>of</strong><br />
maternal and child health services and could be a useful<br />
intervention to accelerate progress towards Millennium<br />
Development Goals for maternal and child health.<br />
1<br />
Basinga. P et al (2011). Effect on maternal and child health services<br />
in Rwanda <strong>of</strong> payment to primary health-care providers for<br />
performance: an impact evaluation. Lancet 2011, 377: 1421-28<br />
22