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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, 1 st November 2012 Presenter: Jenny-Meya Nyirenda National Community Health Specialist, MOH. OUTLINE OF THE PRESENTATION.

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slide1

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 Nyirenda

National Community Health Specialist, MOH

outline of the presentation
OUTLINE OF THE PRESENTATION
  • Part I: National Community Health Assistant (CHA) Strategy
  • Part II: National CHA M&E Framework
  • Part III: CHA Curriculum Review
slide3

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

slide4

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

slide5

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

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

OBJECTIVES OF NCHW STRATEGY

slide6

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

  • 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.
  • 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

slide7

NATIONAL SITUATION ANALYSIS

  • 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
slide8

SITUATION ANALYSIS FINDINGS

  • 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
slide9

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

slide10

FOUNDATION FOR THE NCHW STRATEGY

  • In 2010 MOH created the National Community Health Worker Strategy, in line with its vision and aim of the HRH Strategic Plan
    • i.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.
integration of nchw strategy into national health care system
INTEGRATION OF NCHW STRATEGY INTO NATIONAL HEALTH CARE SYSTEM

Level 3 Hospitals

Level 2 Hospitals

Level 1 Hospitals

slide12

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

Health

Center

Non-Community Health volunteers*

Community Health Structure

Meet new qualification

CHAs

Meet new qualification

Coordinate volunteers

Current Community Health volunteers*

Volunteer CHWs

Don’t meet new qualification

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

slide13

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.

slide14

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

slide15

Selection Criteria for candidates:

  • Minimum Grade 12 and 2 “O” levels
  • 18-45 years old
  • Endorsed by Neighbourhood Health Committee (NHC)
  • Must be living in same area at time of recruitment
  • Preferably 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

slide16

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

slide17

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+ students
    • A national CHA School was built to train 300+

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

scope of work primary healthcare package
SCOPE OF WORK: PRIMARY HEALTHCARE PACKAGE

Family Health Package

Disease Prevention & Control Package

Disease Prevention & Control

Sexual & Reproductive Health

Environmental Health

Maternal & Child Health

  • Infection Prevention
  • Insect and rodent control
  • Home, personal, & food hygiene
  • Excreta disposal
  • Solid and liquid waste disposal
  • Water safety
  • HIV & AIDS & STIs
  • Male Circumcision
  • Malaria (RDTs),
  • Diarrhea
  • Epidemics
  • TB
  • Acute Respiratory Illness (ARI)
  • ANC visits
  • PNC visits (6,6,6)
  • Birth plan
  • Nutrition during, and after pregnancy
  • PMTCT
  • Nutrition and growth monitoring
  • Immunizations
  • Hygiene
  • Adolescent health services
  • Gender issues
  • HIV & AIDS prevention (VCT)
  • Family Planning methods
  • Minor cuts & infections
  • Bandages
  • Emergency care (CPR)

First Aid

Health Education & Communication

  • Health Education Communication Approaches are cross-cutting
  • Schools ▪ NHC / community meetings
  • Churches ▪ Various groups & clubs
cha graduation ceremony on 13 july 2012
CHA GRADUATION CEREMONY ON 13 JULY 2012

Presenting Certificates to 307 CHA Graduates

cha graduation ceremony on 13 july 20121
CHA GRADUATION CEREMONY ON 13 JULY 2012

The First Class of Community Health Assistants Graduate

slide21

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

slide22

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

slide23

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”

slide24

CHA SUPERVISION

  • 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
outline of the meeting
OUTLINE OF THE MEETING
  • Part I: National CHA Strategy
  • Part II: National CHA M&E Framework
  • Part III: CHA Curriculum Review
slide26

MONITORING AND EVALUATION FRAMEWORK

(EVIDENCE GENERATION PLAN)

Health Outcomes Evaluation

Value for Investment Analysis

Process Evaluation

Monitoring

Supervision

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

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

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

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

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

Assess process, functionality & quality of: 1. Training

2. Recruitment

3. Deployment

4. Management

5. Inventory control

6. Supervision

7. Referral system

8. Community acceptance

slide27

MONITORING AND EVALUATION FRAMEWORK

(EVIDENCE GENERATION PLAN)

Health Outcomes Evaluation

Value for Investment Analysis

Process Evaluation

Monitoring

Supervision

Lead: Boston University / ZCAHRD & MoH

Lead: CHAI & MoH

Lead: WHO & Harvard/IPA & MoH

Lead: MOH & CHAI, and IPA

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

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

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 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:

Do CHAs offer high-quality services in compliance with Zambia’s regulatory standards?

outline of the meeting1
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
primary healthcare package for chas
PRIMARY HEALTHCARE PACKAGE FOR CHAS

Disease Prevention & Control Package

Family Health Package

Disease Prevention & Control

Sexual & Reproductive Health

Environmental Health

Maternal & Child Health

  • Infection Prevention
  • Insect and rodent control
  • Home, personal, & food hygiene
  • Excreta disposal
  • Solid and liquid waste disposal
  • Water safety
  • HIV & AIDS & STIs
  • Male Circumcision
  • Malaria (RDTs),
  • Diarrhea
  • Epidemics
  • TB
  • Acute Respiratory Illness (ARI)
  • ANC visits
  • PNC visits (6,6,6)
  • Birth plan
  • Nutrition during, and after pregnancy
  • PMTCT
  • Nutrition and growth monitoring
  • Immunizations
  • Hygiene
  • Adolescent health services
  • Gender issues
  • HIV & AIDS prevention (VCT)
  • Family Planning methods
  • Minor cuts & infections
  • Bandages
  • Emergency care (CPR)

First Aid

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

Health Education & Communication

curriculum review changes to scope of work
CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
  • Family Health
  • 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
curriculum review changes to scope of work1
CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
  • 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.
curriculum review changes to scope of work2
CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
  • 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
curriculum review changes to scope of work3
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
curriculum review changes to scope of work4
CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
      • Male reproductive health issues: Promote Voluntary Medical Male Circumcision for infant and adult males at community level and refer to MC providing sites.
  • 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

primary healthcare package for chas1
PRIMARY HEALTHCARE PACKAGE FOR CHAS

Disease Prevention & Control Package

Family Health Package

Disease Prevention & Control

Sexual & Reproductive Health

Environmental Health

Maternal & Child Health

  • Infection Prevention
  • Insect and rodent control
  • Home, personal, & food hygiene
  • Excreta disposal
  • Solid and liquid waste disposal
  • Water safety
  • HIV & AIDS & STIs
  • Male Circumcision
  • Malaria (RDTs),
  • Diarrhea
  • Epidemics
  • TB
  • Acute Respiratory Illness (ARI)
  • ANC visits
  • PNC visits (6,6,6)
  • Birth plan
  • Nutrition during, and after pregnancy
  • PMTCT
  • Nutrition and growth monitoring
  • Immunizations
  • Hygiene
  • Adolescent health services
  • Gender issues
  • HIV & AIDS prevention (VCT)
  • Family Planning methods
  • Minor cuts & infections
  • Bandages
  • Emergency care (CPR)

First Aid

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

Health Education & Communication

curriculum review recommendations to expand scope of work
CURRICULUM REVIEW- RECOMMENDATIONS TO EXPAND SCOPE OF WORK
  • Recommendations for inclusion to CHA scope of work:
    • Disease Prevention & Control Package
  • Create awareness on Gender-based violence and promote its prevention
  • Promote the new vaccines (H-influenza, Pneumococcal, Rota) and other immunizations for <5 children
  • Provide First Aid for Poisoning
  • 4. Environmental health: Participate in Community Led Total Sanitation (CTLS) programs and coordinate other CHWs for this program.
curriculum review recommendations to expand scope of work1
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.
slide38

Thank You

Twa Lumba!

Zikomo!

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