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National Community Health Worker (NCHW) Strategy in Zambia

Maternal and Newborn Health Conference for Zambia’s Mothers and Babies

Intercontinental Hotel, Lusaka, 1st November 2012

Presenter: Jenny-Meya NyirendaNational Community Health Specialist, MOH

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OUTLINE OF THE PRESENTATION

• Part I: National Community Health Assistant (CHA) Strategy

• Part II: National CHA M&E Framework

• Part III: CHA Curriculum Review

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To have adequately trained and motivated community-based health workforce contributing towards: improved service delivery, attainment of the Millennium Development Goals (MDGs), National Health priorities and reduction of human resource for health crisis.

VISION OF NCHW STRATEGY

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A cost effective, adequately trained and motivated community-based health workforce that will contribute to improved management of malaria, child and maternal health and common preventable health conditions.

GOAL OF NCHW STRATEGY

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1. Increase access to quality basic health services at community level via coordination, referral system and communication with health facilities.

2. To strengthen prevention of common illnesses via coordinated health education and promotion services.

OBJECTIVES OF NCHW STRATEGY

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3. To improve health seeking behaviour via early identification and treatment of simple infectious diseases.

4. To maximize HRH serving the community by shifting basic uncomplicated tasks to CHA community level and thus free nurses time to deal with more technical condition.

5. To coordinate and harmonize activities of other CHWs to ensure provision of quality health care in line with National Community Health Strategy

OBJECTIVES OF NCHW STRATEGY

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Zambia has a serious human resources shortage in

health sector.

A key obstacle to reducing disease burden and

achieving MDGs by 2015.

In 2009, MoH conducted a Situation Analysis to

assess the community health landscape in Zambia

Roles, scope and challenges of facilities/

organizations that incorporated CHW services

NATIONAL SITUATION ANALYSIS

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CHW services needed across all programmes: estimated 23,500 active

CHWs existed in Zambia

Training programs by various partners: duration 2 – 11 weeks, vertical and

not aligned to diverse community health needs

Remuneration: Inconsistent incentive structures for CHWs

Various CHW titles: health promoters, community health advisors, peer

health educators, lay health advocates etc.

MOH policy: Lacked official policy to guide management of CHWs

DMO and implementing partners recommendations: standardization of

guidelines on CHW recruitment, education requirements, training,

remuneration and supervision

SITUATION ANALYSIS FINDINGS

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Evidence from Regional Best Practices: MOH undertook desk review of CHW programs being

implemented in other countries to identify best practices - Malawi, Uganda and Ethiopia.

MOH team conducted a study visit to Ethiopia.

Development of Zambia’s CHW strategy: Current national situation analyzed and lessons learnt from other

countries applied .Collaborative consensus-driven process with all key stakeholders.

FOUNDATION FOR THE NCHW STRATEGY

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In 2010 MOH created the National Community Health Worker Strategy, in line with its vision and aim of the HRH Strategic Plani.e. bringing quality, cost effective and affordable health

services as close to the family as possible

Phased implementation process (pilot & 4 phases)

in-built monitoring and evaluation component.

FOUNDATION FOR THE NCHW STRATEGY

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INTEGRATION OF NCHW STRATEGY INTO NATIONAL HEALTH CARE SYSTEM

Level 3 Hospitals

Level 2 Hospitals

Level 1 Hospitals

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INTEGRATION OF NCHW STRATEGY INTO THE NATIONAL HEALTH CARE SYSTEM

MOH has formalized Community Health Workforce, it is now named: “Community Health Assistant” (CHA)CHAs are not intended to replace the existing network of community health volunteers, but rather coordinate and enhance their efforts

Community Health Structure

Volunteer CHWsVolunteer CHWs

CHAsCHAs

Meet new qualification

Don’t meet new qualification

Coordinate volunteers

Non-Community Health

volunteers*

Non-Community Health

volunteers*

Meet new qualification

Current Community Health volunteers*Current Community Health volunteers*

Health CenterHealth Center

*A Community Health Volunteer is defined as a non-formalized volunteer who has typically received 2 – 5 weeks of training

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CAREER PROGRESSION FOR COMMUNITY HEALTH ASSISTANTS

Trainees must have 2 ‘O’ levels.

They can pursue the required Grade 12 certificates so that they can enroll in training as nurses, EHTs, Clinical Officers, or Doctors.

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Pilot’s Geographic Reach: 7 Provinces, 47 most rural districts

and 161 remote health posts

MoH defined selection criteria for Health Posts

Defined as “hard-to-reach” Have a nearby Health Centre for

supervision Have poor health indicators Health posts without a health

worker or manned by an unqualified staff

RECRUITMENT PROCESS FOR CHA CANDIDATES

*2010 GRZ Health Facility Listing

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Selection Criteria for candidates:Minimum Grade 12 and 2 “O” levels18-45 years oldEndorsed by Neighbourhood Health Committee (NHC)Must be living in same area at time of recruitmentPreferably previously/currently working as community

volunteers and females.

Selection of candidates:– Selection panel: NHC, Health Center staff & DMO– 40-50 candidates were selected from 7 provinces (Yr 1)

Outcome: Pilot class of 307 students

RECRUITMENT PROCESS FOR CHA CANDIDATES

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Modular training - theory and practice - a

set of 11 modules

Training Plan –integrated & skills-based

learning model – theory then practical

Primary healthcare focus: prevention,

promotion and basic curative services

Duration: 1 year training

Training Registered: By MoH & HPCZ

CHA TRAINING OVERVIEW

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CHA TRAINING OVERVIEW

• An assessment of potential training sites was conducted in 7 Provinces in 2010

• Major finding: no existing GRZ school had the capacity to train 300+ studentsA national CHA School was built to train 300+

Picture: Exterior and interior view of classrooms in Ndola, Copperbelt Province

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Sexual & Reproductive Health

First Aid

Disease Prevention & Control

Disease Prevention & Control Package Family Health Package

• HIV & AIDS & STIs• Male Circumcision • Malaria (RDTs), • Diarrhea • Epidemics• TB• Acute Respiratory Illness

(ARI)

• Infection Prevention• Insect and rodent

control • Home, personal, &

food hygiene • Excreta disposal• Solid and liquid

waste disposal• Water safety

• Minor cuts & infections• Bandages• Emergency care (CPR)

• Adolescent health services

• Gender issues• HIV & AIDS prevention

(VCT) • Family Planning

methods

•ANC visits•PNC visits (6,6,6)•Birth plan•Nutrition during, and after pregnancy•PMTCT •Nutrition and growth monitoring •Immunizations•Hygiene

Health Education Communication Approaches are cross-cutting• Schools ▪ NHC / community meetings• Churches ▪ Various groups & clubs

Environmental Health

Health Education & Communication

Maternal & Child Health

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CHA GRADUATION CEREMONY ON 13 JULY 2012

Presenting Certificates to 307 CHA Graduates

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CHA GRADUATION CEREMONY ON 13 JULY 2012

The First Class of Community Health Assistants Graduate

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Registration: Qualified CHAs licensed

by Health Professions Council of

Zambia

Allocation: 2 CHAs per Health Post to

serve their communities, a catchment

area of 3,500 people

Remuneration: a monthly incentive

Establishment posts: MoH will seek

Cabinet authority for both CHA School

staff and graduates

CHA DEPLOYMENT

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Supplies ordered from supervising health centre

Training provided within CHA curriculum

Supervisor to verify records and monitor

consumption used at household & post level

Diagnostics: TB sputum specimen containers,

Rapid Diagnostic Test and Rapid HIV test kits

*For full drug list, please see handout

CHA DRUG SUPPLY CHAIN

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DATA MANAGEMENT

CHAs trained in data management Using standard MOH/CHA registers and

reporting formats Compile 1 monthly report per HP Submit two sets of report– hard copy to Supervisor – Electronic copy using a mobile phone via

internet to Districts, Provinces and MoH-HQ System is a building block for MoH’s

“community HMIS”

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Professional health worker In-Charge at “parent” health center supervises CHAs on monthly basis

In-Charge was trained and equipped with:

Supervisor’s manual and supervisory tools

resources to facilitate regular supervisory visits

CHA SUPERVISION

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OUTLINE OF THE MEETING

• Part I: National CHA Strategy

• Part II: National CHA M&E Framework

• Part III: CHA Curriculum Review

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MONITORING AND EVALUATION FRAMEWORK (EVIDENCE GENERATION PLAN)

Health Outcomes Evaluation

Leads: Boston University / ZCAHRD & MoH, and CHAI

Generate data on:

1. Treatment of children < 5 for malaria, diarrhea & ARI

2. % deliveries with a skilled birth attendant

3. Family planning acceptance rate

4. % neonates receiving post-natal checkup within 1 month

Value for Investment Analysis

Leads: CHAI & MoH

Document the effect of CHAs on the health system:

1. Volume and type of patient visits by cadre

2. Productivity of cadres

3. Total costs of training & employing each cadre

Analyze: Productivity vs. cost each cadre

Process Evaluation

Leads: MoH, CHAI & Innovations for Poverty Action (IPA)

Assess process, functionality & quality of: 1. Training

2. Recruitment

3. Deployment

4. Management

5. Inventory control

6. Supervision

7. Referral system

8. Community acceptance

Monitoring

Leads: MOH, CHAI and IPA

Assess achievement of targets:

1. # of household visits per month

2. # and types of procedures carried out

3. # of children < 5 attended

4. # of pregnant women attended

5. Follow up with referrals

Supervision

Leads: In Charge at “Parent” Health Centers, ZISSP, & CHAI

Assess and support:

1. Quality of CHA services

2. Compliance with approved Scope of Work

3. Use of medications and supplies

4. Provide feedback to improve CHA performance

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MONITORING AND EVALUATION FRAMEWORK

(EVIDENCE GENERATION PLAN)Health Outcomes

Evaluation

Lead: Boston University / ZCAHRD & MoH

Value for Investment Analysis

Lead: CHAI & MoH

Process Evaluation

Lead: WHO & Harvard/IPA & MoH

Monitoring

Lead: MOH & CHAI, and IPA

Supervision

Lead: In Charge at “Parent” Health Centers, ZISSP

Key policy question answered:

Do CHAs improve

community access to health

care?

Key policy question answered:

Do CHAs improve

community access to health

care?

Key policy question answered:

What is the most productively

efficient skill mix of cadres for the Zambian health

workforce?

Key policy question answered:

What is the most productively

efficient skill mix of cadres for the Zambian health

workforce?

Key policy question answered:

What changes should be made

to the CHA Strategy prior to

the national scale up?

Key policy question answered:

What changes should be made

to the CHA Strategy prior to

the national scale up?

Key policy question answered:

Are CHAs reaching the

priority populations as

expected?

Key policy question answered:

Are CHAs reaching the

priority populations as

expected?

Key policy question answered:

Do CHAs offer high-quality services in

compliance with Zambia’s

regulatory standards?

Key policy question answered:

Do CHAs offer high-quality services in

compliance with Zambia’s

regulatory standards?

Leads: Boston University / ZCAHRD & MoH, and CHAI

Leads: CHAI & MoH Leads: MoH, CHAI & Innovations for Poverty Action (IPA)

Leads: MOH, CHAI, and IPA

Leads: In Charge at “Parent” Health Centers, ZISSP, & CHAI

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OUTLINE OF THE MEETING

• Part I: National CHA Strategy

• Part II: National CHA M&E Framework

• Part III: CHA Curriculum Review for the National Scale up

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PRIMARY HEALTHCARE PACKAGE FOR CHAS

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Sexual & Reproductive Health

First Aid

Disease Prevention & Control

Disease Prevention & Control Package Family Health Package

• HIV & AIDS & STIs• Male Circumcision • Malaria (RDTs), • Diarrhea • Epidemics• TB• Acute Respiratory

Illness (ARI)

• Infection Prevention• Insect and rodent

control • Home, personal, &

food hygiene • Excreta disposal• Solid and liquid

waste disposal• Water safety

• Minor cuts & infections• Bandages• Emergency care (CPR)

• Adolescent health services• Gender issues• HIV & AIDS

prevention (VCT) • Family

Planning methods

•ANC visits•PNC visits (6,6,6)•Birth plan•Nutrition during, and after pregnancy•PMTCT •Nutrition and growth monitoring •Immunizations•Hygiene

Health Education Communication Approaches are cross-cutting• Schools ▪ NHC / community meetings• Churches ▪ Various groups & clubs

Environmental Health

Health Education & Communication

Maternal & Child Health

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CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK

Family Health

1.Family Planning: counsel, initiate and refill oral contraceptives

- Integrate HIV testing and couple counseling with FP services

- Injectable contraceptives (Depo-Provera) by CHAs pending decision by Health Professional Counsel of Zambia (HPCZ).

- Birth spacing counseling, including for HIV positive couples and pregnant women to be added to CHA’s competencies

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CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK

2. Provide pregnancy care (ANC) and Life Saving Skills during delivery at point of care

Initiate early ANC follow up by referring to health facilities

– pregnancy test

– hemoglobin (Hb)

– Urine test (using dipstick)

– Refer pregnant mothers with high sugar and protein level in their urine.

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CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK

3. Train and equip CHAs with skills to:

Conduct emergency delivery procedures (not as routine service), in addition to referring mothers to deliver at health facilities.

Provide misoprostol in emergency situations

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CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK

4. Postpartum care- at household level:- CHAs to conduct 48- 72 hour post natal follow up of

mothers with their babies

- Refer those with signs of post partum infection or any abnormality to a health facility.

Provide WHO’s Essential Newborn Care including:

– routine neonatal care, resuscitation skills,

– thermoregulation, "kangaroo" [skin-to-skin] care,

– breast-feeding, care of the small baby,

– common illnesses

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CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK

5. Male reproductive health issues: Promote Voluntary Medical Male Circumcision for infant and adult males at community level and refer to MC providing sites.

6. Nutrition: integrated approach in all modules

- Promote/demonstrate child feeding practices through food preparation using locally available foods.

- Anemia- administer iron supplements for pregnant women

- Vitamins – administer to malnourished children.

7. HIV: Provide VCT services for adults, children, pregnant mothers…integrated with other services

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PRIMARY HEALTHCARE PACKAGE FOR CHAS

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Sexual & Reproductive Health

First Aid

Disease Prevention & Control

Disease Prevention & Control Package Family Health Package

• HIV & AIDS & STIs• Male Circumcision • Malaria (RDTs), • Diarrhea • Epidemics• TB• Acute Respiratory

Illness (ARI)

• Infection Prevention• Insect and rodent

control • Home, personal, &

food hygiene • Excreta disposal• Solid and liquid

waste disposal• Water safety

• Minor cuts & infections• Bandages• Emergency care (CPR)

• Adolescent health services• Gender issues• HIV & AIDS

prevention (VCT) • Family

Planning methods

•ANC visits•PNC visits (6,6,6)•Birth plan•Nutrition during, and after pregnancy•PMTCT •Nutrition and growth monitoring •Immunizations•Hygiene

Health Education Communication Approaches are cross-cutting• Schools ▪ NHC / community meetings• Churches ▪ Various groups & clubs

Environmental Health

Health Education & Communication

Maternal & Child Health

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CURRICULUM REVIEW- RECOMMENDATIONS TO EXPAND SCOPE OF WORK

• Recommendations for inclusion to CHA scope of work:• Disease Prevention & Control Package

1. Create awareness on Gender-based violence and promote its prevention

2. Promote the new vaccines (H-influenza, Pneumococcal, Rota) and other immunizations for <5 children

3. Provide First Aid for Poisoning

4. Environmental health: Participate in Community Led Total Sanitation (CTLS) programs and coordinate other CHWs for this program.

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CURRICULUM REVIEW- RECOMMENDATIONS TO EXPAND SCOPE OF WORK

5. Prevention and control of common chronic illness:

- Conduct rapid blood glucose test and urine test for sugar to diagnose Diabetes among people with signs and symptoms and refer to health facilities.

- Promote health lifestyle and prevention of chronic illnesses like diabetes and hypertension.

- Provide adherence counseling for patients on medication for chronic illnesses and refer the “lost to follow up” clients to health facilities for re-start.

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Thank You

Zikomo!

Twa Lumba!