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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!