Role of Poverty on Participation and Outcomes in an Integrated Child Survival-Early Childhood Development Project in Rwanda

background: A four-year integrated child survival (CS) and early childhood development (ECD) project sought to improve maternal and child health and child development outcomes in a pilot site in Rwanda.  A mixed-methods evaluation explored whether the project achieved its objectives and equitably provided services designed to support individual- and community-level benefits.

methods: Knowledge, Practice, and Coverage (KPC) survey data measured household characteristics, maternal and child health behaviors and practices, and program exposure among baseline and endline cross sections of women with a child under two years of age in intervention and comparison sites. Endline qualitative data were collected via focus group discussions with community health workers and participating mothers.

results: Based on qualitative data, despite equitable access to the project and a policy whereby no one was turned away, poorer families were inclined to self-regulate their participation when unable to contribute to project costs. Child absence from ECDs also was attributed to poor health, linked to an inability to afford health insurance and seek care. Poorer families reportedly had a harder time understanding instructions, maintaining food security and purchasing supplies for high nutrient feeding and ECD activities. There remained significant differences at endline in CS-related KPC outcomes by socio-economic status, particularly for indicators of child underweight and stunted, treatment access for childhood illnesses, and contraceptive use.

conclusions:  The intervention had limited ability to fully address poverty-related inequities on child survival outcomes. Future efforts should incorporate adaptive and participatory approaches benefitting the most poor, in conjunction with poverty reduction programming.