THE GLOBAL FUND to FIGHT AGAINST AIDS,
TB AND MALARIA (GFATM)
Report on
GLOBAL FUND ROUND 8 HSS GRANT COMMUNITY
SYSTEMS STRENGTHENING (CSS) EVALUATION
August 2012
Table of Contents
ACKNOWLEDGEMENTS ............................................................................................................. 1
ABBREVIATIONS AND ACRONYMS ............................................................................................. 2
EXECUTIVE SUMMARY ............................................................................................................................. 4
CHAPTER 1: INTRODUCTION ................................................................................................................... 8
1.1
Background .................................................................................................................................. 8
1.2
CSS programme context .............................................................................................................. 8
1.3
Objectives of the evaluation study .............................................................................................. 9
CHAPTER 2: METHODOLOGY ................................................................................................................. 11
2.1.
Evaluation design ........................................................................................................................ 11
2.2.2
Primary data collection ............................................................................................................... 11
2.2.3
Data analysis ............................................................................................................................... 12
2.2.4
Limitations of the study .............................................................................................................. 13
CHAPTER 3: FINDINGS- PROGRAM DESIGN....................................................................................... 14
3.1
Programme relevance and quality of design ............................................................................. 14
3.2
Evidence of incorporation of community-based approaches into program strategies ........... 14
3.2.1
The national health strategy ....................................................................................................... 14
3.2.2
Program strategies ...................................................................................................................... 15
3.3
CHWs participation and contribution to HIV, TB, malaria and MNCH programs ................ 16
3.3.1
CHWs participation in the programs ......................................................................................... 16
3.3.2
Contribution of CHWs in disease programs .............................................................................. 17
3.4
Sustainability of CHW component beyond GF support ........................................................... 18
3.4.1
Ownership and recognition of CHWs by the community ......................................................... 18
3.4.2
Funding of CHW program .......................................................................................................... 18
CHAPTER 4: FINDINGS - PROGRAM IMPLEMENTATION .................................................................. 21
4.1
Adherence to work plan .............................................................................................................. 21
4.1.1
Timeliness of implementation ................................................................................................... 21
4.1.2
Completeness of implementation .............................................................................................. 21
4.1.3
Delivery approaches.................................................................................................................... 21
4.1.4
Adherence to national guidelines and targets .......................................................................... 22
4.2
Capacity of CHWs to implement planned interventions ......................................................... 22
4.2.1
Training requirements ............................................................................................................... 22
4.2.2
Appropriate skills-mix ............................................................................................................... 23
4.2.3
Adequacy of supervision of CHWs ............................................................................................ 23
4.2.4
Adequacy of logistical support .................................................................................................. 24
4.3
Coordination and communication between organizations ..................................................... 24
4.4
Facilitating and inhibiting factors in implementation of CHW programme .......................... 25
4.4.1
Facilitating factors ..................................................................................................................... 25
4.4.2
Inhibiting factors ....................................................................................................................... 28
CHAPTER 5: FINDINGS - PROGRAM RESULTS ................................................................................... 30
5.1
Perception of community members and leaders on CHW programme .................................. 30
5.1.1
Strengths and weaknesses ......................................................................................................... 30
5.1.2
Perceptions ................................................................................................................................. 30
5.2
Results of community interventions ......................................................................................... 30
5.2.1
Malaria........................................................................................................................................ 30
5.2.2
HIV/AIDS .................................................................................................................................... 31
5.2.3
TB ................................................................................................................................................ 32
5.3
Cost effectiveness of Global Fund support ............................................................................... 33
CHAPTER 6: SUMMARY FINDINGS ....................................................................................................... 35
CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS ................................................................. 36
7.1
Conclusions ................................................................................................................................ 36
7.1.1
Programme design ..................................................................................................................... 36
7.1.2
Programme implementation ..................................................................................................... 36
i
7.1.3
7.1.4
7.1.5
7.2
Programme results ..................................................................................................................... 36
Potential impact ......................................................................................................................... 36
Sustainability .............................................................................................................................. 36
Recommendations ..................................................................................................................... 36
ANNEXES ................................................................................................................................................... 39
Annex 1: Terms of Reference for the Zimbabwe CSS Evaluation ............................................................ 39
Annex 2: References ................................................................................................................................... 42
Annex 3: Criteria for selection of VHWs ................................................................................................... 43
Annex 4: Training curriculum for VHWs .................................................................................................. 44
Annex 5: Training curriculum for CBHWs................................................................................................ 46
Annex 6: A Story of Change by the Dumbamwe Clinic CBHC Team ....................................................... 48
Annex 7: Facility Based Examples of Battery Scores Before and After the Training (CHWs) ............... 50
Annex 8: Evaluation Framework ................................................................................................................ 51
Annex 9: List of people met and summaries of CHWs met in FGDs ....................................................... 56
ii
ACKNOWLEDGEMENTS
We would like to thank all the officials of the Ministry of Health and Child Welfare (MoHCW)
who participated in this evaluation at national, provincial, district and community levels. To
the members of the Country Coordinating Mechanism (CCM) Secretariat and the CCM Health
Systems Strengthening (HSS) sub-committee who participated in the feedback consultative
meeting we are indebted for their contribution in developing the recommendations of this
study.
We would also like to appreciate the role played by the provincial and district health leadership
team and the many health workers we met including the Mashonaland West Provincial Health
Executive (PHE), the Chegutu and Makoni District Health Executives (DHE), Manicaland
Provincial Nursing Officer (PNO), the local leadership, the Village Health Workers (VHW) and
Community Home Based Caregivers (CHBC).
We are also very grateful for the insights that we gathered from the discussions we had with
members of the World Health Organisation (WHO) and United Nations Children’s Fund
(UNICEF) teams particularly the stories shared on the experience gained during the
resuscitation of the VHW programme. The revamped VHW programme coincided with the
cholera outbreak of 2008-09, a precursor to the decision to allocate further funding from
Global Fund and the proposed UNICEF managed Health Transition Fund. Additional inputs
were also received from representatives of the Principal Recipient, United Nations
Development Programme (UNDP).
Notwithstanding all the assistance received and the opinions expressed by those mentioned
above and others too many to enumerate, the consulting team takes full responsibility for any
errors of commission and omission contained in his report.
1
ABBREVIATIONS AND ACRONYMS
AIDS
ANC
ART
ARVs
ASRH
CBO
CCM
CHBC
CHW
CMAM
CSS
DAC
DBS
DHE
DHIS
DNO
DOT
EHT
EID
FGD
FHW
GF/GFATM
GoZ
HBC
HIV
HMIS
HOSPAZ
HSS
HTC
HTF
IEC
IMNCI
IP
IPT
ITN
KII
LLIN
M&E
MCH
MDG
MDR
MER
MNCH
MoHCW
MSC
NARF
NGO
OI
PHC
PHE
PLA
PLWHA
PMTCT
Acquired Immune Deficiency Syndrome
Antenatal Care
Anti-Retroviral Therapy
Anti-Retroviral (drugs)
Adolescent Sexual and Reproductive Health
Community Based Organisation
Country Coordinating Mechanism
Community and Home Based Care-giver (C&HBC)
Community Health Worker
Community Management of Acute Malnutrition
Community Systems Strengthening
Development Assistance Committee
Dry Blood Spot
District Health Executive
District Health Information System
District Nursing Officer
Directly Observed Therapy
Environmental Health Technicians
Early Infant Diagnosis
Focus Group Discussion
Farm Health Worker
The Global Fund to fight AIDs, Tuberculosis and Malaria
Government of Zimbabwe
Home Based Care
Human Immunodeficiency Virus
Health Management Information System
Hospice Association of Zimbabwe
Health Systems Strengthening
HIV Testing and Counselling
Health Transition Fund
Information Education and Communication
Integrated Management of Neonatal and Childhood Illnesses
Implementing Partner
Intermittent Presumptive Therapy
Insecticide Treated Nets
Key Informant Interview
Long Lasting Insecticidal Net
Monitoring and Evaluation
Maternal and Child Health
Millennium Development Goals
Multi Drug Resistant (TB)
More Efficacious Regimen
Maternal Neonatal and Child Health
Ministry of Health and Child Welfare
Most Significant Change
National AIDs Reporting Forms
Non Governmental Organisation
Opportunistic Infections
Primary Health Care
Provincial Health Executive
Participatory Learning and Action
People Living With HIV and AIDS
Prevention of Mother to Child Transmission of HIV
2
PNC
PNO
PR
PRA
RDC
RHC
RTD
SRS
STI
T&C
TB
UIN
UNDP
UNICEF
VCT
VHT
VHW
WASH
WHO
ZAN
ZNASP
Post Natal Care
Provincial Nursing Officer
Principal Recipient
Participatory Reflective and Appraisal techniques
Rural District Council
Rural Health Centre
Rapid Diagnostic Test (Malaria)
Simple Random Sampling
Sexually Transmitted Infection
Testing and Counselling
Tuberculosis
Unique Identifier Number
United Nations Development Programme
United Nations Children’s Fund
Voluntary Counselling and Testing
Village Health Team
Village Health Worker
Water and Sanitation Hygiene
World Health Organization
Zimbabwe Aids Network
Zimbabwe National AIDS Strategic Plan
3
EXECUTIVE SUMMARY
0.1
Background
In 2009 the Government of Zimbabwe applied for funding assistance from the Global Fund
Health Systems Strengthening grant. The goal was to achieve a more effective health delivery
system by strengthening the community health systems to ensure that there were trained
personnel at community level to provide health services. In April 2012, the Global Fund
contracted PricewaterhouseCoopers, the Local Fund Agent to carry out an evaluation study of
the Community Health Worker program.
The objectives of the evaluation are, to:
-
assess if investments in CHW programs has improved the effectiveness, efficiency and
results of the HIV/AIDS, TB and malaria programs in Zimbabwe; and,
-
provide a comprehensive analysis of potential options for improving efficiency and
effectiveness of CHW programs, with clear recommendations for preferred options for
continued funding.
A cross-sectional study that used the mixed method approaches was used to draw primary
data from the CHWs, the beneficiary communities and their leaders, other health workers and
implementing partners at all levels. Secondary data from disease specific databases was also
obtained to identify the impact of the work of CHWs on the GF target disease trends. The main
issues investigated were the effects of the GF investments in the CHW program on the
HIV/AIDS, TB and malaria programs. An analysis of potential options for improving the CHW
programme was also done.
0.2
Relevance and quality of design
The CHW is in-line with the strategic focus at both the national level and for the individual
disease components. For example, the community-based approach is one of the five pillars of
the National Health Strategic Plan (2011-2015) which is dedicated to community participation.
Seven (22%) of the 32 goals, and 58 (42%) of 138 objectives contained in the strategic plan
cannot be implemented effectively and adequately without the involvement of CHWs whose
role is critical in implementing the preferred community based approach.
There was strong evidence that the CHW program was relevant and appropriate in supporting
the primary health care approach anchored on community involvement and participation in
improving awareness, access and utilization of health services. At all levels of the health care
system, there is an appreciation of the importance and necessity of the contribution of CHWs
in supporting the health care system.
0.3
Program implementation
0.3.1 Efficiency
A total of 11,514 CHWs were trained compared to the target of 11,160. This was achieved at an
average cost of $8 per person per day over the three weeks compared to the planned cost of
$23 per person per day. The program demonstrated efficiency in as far as more CHWs were
trained than planned. However, the program was not efficient in the distribution of incentives
as fewer CHWs received their allowances from the sixth quarter.
0.3.2 Effectiveness
4
The program was effective in ensuring that there was a trained community cadre who provided
both preventive and curative health services. This reduced the distance travelled as well as the
cost of transport incurred by members of the community in seeking health services. The
program managed to enhance the knowledge and skills of the trained CHWs. The CHBCs were
reported to be better positioned to provide quality care to PLWHAs and their families
addressing physical, emotional, spiritual and social needs. Similarly, the capacity of the VHWs
to provide health education as well as to identify, manage and refer cases was noted to be
significant. However the effectiveness of the CHWs was affected by their numerical
inadequacy, and inadequate support in terms of supplies, incentives, supportive supervision
and mentoring. There is also lack of integration of the VHW reporting system into the Health
Information Systems (HIS) resulting in non-transmission and unavailability of VHW
performance data at all levels.
0.3.3 Impact
In the short time the program has been implemented its impact on the HIV, TB and malaria
programs is difficult to discern partly due to the absence of comprehensive performance
measurement data. Nonetheless, the impact prospects in the long term are perceived to be
good by most of the informants encountered during the study. Already, the training given to
the CHWs is reported to have contributed towards improved detection of malaria cases as well
as increased participation by members of beneficiary communities during awareness
campaigns.
0.3.4 Coordination
This VHW program was observed to be operating within established coordination structures
of the MoHCW. The VHW component was supervised under the Directorate of Nursing and
was recognised at the various supervisory structures (provincial and district levels) of the
MoHCW. The coordination of the CHBCs was led by ZAN, HOSPAZ and implementing
partners. Broadly, the coordination for both VHWs and CHBCs contributed to the successful
implementation of the planned activities.
Some gaps were however noted in the coordination of the VHWs. Coordination should
recognise the complementary role of all stakeholders in achieving planned goals through
regular sharing of results and maintaining proper flow of information. Some key stakeholders
were left out of the vital processes such as planning, development of VHW training curricular,
training of VHWs, supervision and management meetings.
The most essential ingredients of system-strengthening approaches such as strategic
leadership, and efforts towards strengthening linkages between the vital parts/levels of the
system were suboptimal. This limits the ability of the CSS grant to materially affect the buildup of results towards achievement of the goals of the National Health Strategic Plan.
0.4
Sustainability of results
Although currently the Government of Zimbabwe is still facing liquidity challenges as the
economy undergoes the recovery process, there are indications that the CHW programme will
remain a critical component of the National Health Strategy. Therefore, in the short and
medium term, donor funding will be crucial in sustaining current efforts in supporting the
Health System in general including the CSS program.
In addition, it was noted that the Global Fund is supporting the CSS program through the HSS
grant as well as through the other three disease specific grants under Round 8 Phase 1 and
Phase 2. The desired position is for the GoZ to progressively increase funding for CHWs
program in the long term.
5
0.5
Recommendations
Based on these findings, the following recommendations are hereby proffered to GFATM and
stakeholders in the CSS Program:

Harmonization and standardization of training
There is need to have one standardised training manual for the different groups of CHWs and
this should be based on the harmonization of the integrated VHW and CBHC training
modules. There should be a minimum training package for all community health workers,
which should be developed in consultation and active involvement of all the relevant
departments like Environmental Health, Nursing, Health Promotion, MCH, HMIS to name
but a few.
An annual mapping exercise should be conducted that provides for the identification of CHWs
by District, contact Health facility, level of training, community of responsibility, and schedule
of incentives to be received and/or received to date. It is envisaged that harmonization and
standardization of the training of the VHW and CBHC training packages would contribute to
improvements in numerical adequacy of the CHWs. The mapping exercise would also identify
who is doing what, where in terms of partner support for CSS so that further efforts can be
directed to ensure equity.

Incentive package
There is need for a standardised incentive package across the CHWs, and improve
transparency and communication around the incentives vis-à-vis commensurate facilitation
for CHW workload.

Procurement and supply management of pharmaceutical and medical
products
There is need to strengthen the overall supply chain systems to ensure reliable and adequate
pharmaceuticals and supplies for health facilities that take into account the needs of the
CHWs.

Supervision, support and mentorship
The current support and supervision should first and foremost emphasise frequency of
support visits from the focal health facility to the CHWs in their workplaces. Deliberate efforts
toward balancing the interactions of both the nurse and the EHT in supervising the CHWs will
go a long way in improving the technical capacity, scope of both preventive and curative
interventions as well as and quality of services provided by the CHW.

Monitoring and evaluation
The CHWs should be regularly and more reliably provided with registers and simplified
summary reporting forms. The HMIS and DHIS should be revised to provide sections for CHW
reporting. A comprehensive M&E framework and system that includes a set of indicators on
provision of necessary inputs, CHW service coverage, and means of measuring performance
of the CSS programme should also be developed.
6

Coordination
There is need for a shared understanding of the results the CSS programme seeks to achieve
in order to improve health service delivery in the country (strategies, goals and objectives), as
well as promote clarity and commonality of purpose among key CHW user departments. Given
the cross-departmental and integrated management nature of the CSS grant, there is need to
separate the strategic and operational functions of the CSS program management through
establishment of a ‘home’ to coordinate the routine operational and administrative affairs of
the CSS program.

Sustainability and options for continued funding
The Government is encouraged to continue increasing their allocation and disbursements to
the programme from the current 6.7 % towards 100% of total need in the long term. We further
recommend that incentives such as allowances, uniforms and bicycles be considered a
necessary component of the CSS programs at all times.
The Global Fund should provide funding for the component through one grant, the HSS grant
to enable a more centralised coordination of the trainings of the CHWs. At the moment
funding for the component is provided through all the four grants.
7
CHAPTER 1: INTRODUCTION
1.1
Background
In 2009, the Government of Zimbabwe (GoZ) successfully applied for grant funding under the
Round 8 of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), Health
Systems Strengthening (HSS) program. The program was established as a crosscutting grant
whose goal was to achieve a strengthened and more effective health delivery system through:
retention of the health sector workforce; strengthening community health systems; and,
raising the scale of operation of community programs focusing on HIV/AIDS, TB and malaria.
The component focusing on strengthening Community Health Systems was aimed at ensuring
that there were sufficient numbers of trained staff at community level to provide health
services.
In line with the GFTAM funding mechanisms, UNDP, the Principal Recipient for the GF has
since 2010 (when the GF Round 8 grants were first implemented) been overseeing the
implementation of the grant aimed at providing support to the Community Health Workers
(CHW) under the management of the Ministry of Health and Child Welfare (MoHCW) and
Zimbabwe AIDS Network (ZAN). The MoHCW is responsible for managing the Village Health
Worker (VHW) sub-component while ZAN is responsible for the Community Home Based
Care Givers (CHBC) sub-component. The funding for the whole component was targeted at
supporting the training of CHW and the provision of allowances and uniforms to complement
other Government efforts.
In April 2012 the Global Fund engaged PricewaterhouseCoopers (PwC), the Local Fund Agent,
to carry out an evaluation of the Community Systems Strengthening component in partial
fulfillment of the conditions for signing of the HSS Phase 2 Grant.
1.2
CSS programme context
Service delivery in the health sector is predicated on a two pronged approach. On one hand is
the primary health care approach (PHC) which emphasizes the prevention of diseases and the
promotion of health in the family and the community as a whole. On the other hand, the
medical care approach focuses on helping individuals after they have fallen ill. It is important
that these two approaches complement each other to ensure effective delivery of health care
services. Several attempts have been made to achieve this objective resulting in the CHW
programme being placed under different government bodies to play different roles within the
community, at different times since its inception. For example, during the 1990s the
programme was under the oversight of both the Nursing and Environmental Health
departments, when it was realised that both departments needed to collaborate closely in
order to achieve a more holistic and better capacitated community cadre.
CSS programme management
The provision of training, supplies and the implementation of community work by the CHWs
complemented by incentives and on-going supervision by health workers define the key
processes of the model used for the CSS programme. These processes require essential inputs
which include: health professionals; national strategic documents to provide guidance; strong
Monitoring and Evaluation Systems; a good coordination mechanism; committed members of
the community who meet the criteria and are willing to do the work; funds for transportation;
venues and other workshop expenses; training modules; supplies for use in the field; as well
as incentives for the CHWs.
8
It is therefore clear that the coordination mechanism for the CSS needs to involve the nursing
as well as the environmental health and health promotion departments/sections of the
MoHCW, and the relevant development and implementation partners. In order to monitor the
activities of the CHWs, follow disease trends, plan supplies and logistics and support
supervision, such coordination mechanisms also needs to be replicated all the relevant levels
(provincial, district and health facilities).
Expected results of CSS
The work of the trained CHWs is mainly to provide preventive and promotional health services
but with occasional treatment of minor ailments in the communities. Health education and
promotion, case identification and referral as well as community mobilisation are therefore
significant activities undertaken by the CHWs particularly the VHW. These activities should
contribute to the realisation of health related results in the short, medium and long term.
The programme is expected to position a trained and committed cadre facilitating prevention
through awareness and education, early identification of cases and referrals as well as
generally responding to the health needs of the community. These activities are also expected
to improve awareness of available health services and participation by the community.
The existence of numerically adequate and capacitated CHWs in terms of knowledge, skills
and resources is envisaged to result in improved access to health services and positive change
in the communities’ health seeking behaviour. The latter is largely characterized by enhanced
utilization of the available health services. In the medium term, improvements are expected
in the uptake of antenatal care, post natal care, immunization, family planning and voluntary
counselling and testing. These results collectively contribute to the reduction in morbidity and
mortality within the communities and the attainment of the Millennium Development Goals
(MDGs) at the broader level. Figure 1 illustrates the CSS programme theory of change.
1.3
Objectives of the evaluation study
The key objectives of the evaluation are, to:

assess if investments in CHW programs, has improved the effectiveness, efficiency and
results of the HIV/AIDS, TB and malaria programs in Zimbabwe; and,

provide a comprehensive analysis of potential options for improving efficiency and
effectiveness of CHW programs, with clear recommendations for preferred options for
continued funding.
The intervention logic of the CSS programme was an essential entry point for this evaluation.
Consultations with key stakeholder representatives and a review of the National Strategic
Plans and HSS/CSS proposal were useful in defining the programme’s intended results. A
review of documents and consultations with key stakeholder representatives clarified the
mechanism established to manage the CHW programme at strategic, operational and tactical
levels
9
IMPACT

Reduction in morbidity and mortality/Attainment of the MDGs/Eradicate disease
OUTCOMES

Improved awareness and use of preventive
methods incl. hygiene and nutrition practices

Equitable access to available health services

Improved health seeking behaviour: Uptake of
ANC, PNC, EPI, FP and VCT

Improved reception of referred cases

Improved detection of outbreaks
OUTPUTS

Trained CHWs

Community coverage of health information

Community awareness of available health services

Cases identified and managed or referred

Improved participation in community health
INPUTS

Health professional (Trainers, supervisors)

Vehicles, fuel, training venues, stationery

Strategic plans and guidelines

Standard training modules

Simple treatment kits/supplies

CHW Kits

Tools and Incentives (Allowances, bicycles,
uniforms, stationery)

Community members meeting CHW criteria
PROCESSES- Health
Professional

Training

Support & supervision

Supply Replenishment

Provision of allowances

Provision of uniforms,
bicycles, tool kits,
torches

Recording/Report
writing

The “Three Ones”
Figure1: CSS Project Theory of Change
.
10
PROCESSES- CHW






Health education
Health promotion
Treatment of minor
illnesses
Case identification and
referral
Community
mobilisation
Recording/Report
writing
CHAPTER 2: METHODOLOGY
2.1.
Evaluation design
The Development Assistance Committee (DAC) of Organisation of Economic Cooperation and
Development (OECD) has developed comprehensive criteria for carrying out evaluation
studies. The guidelines developed focus on assessing the following attributes: relevance and
quality of design, efficiency, effectiveness, impact and sustainability of program initiatives.
The consulting team adapted the DAC criteria to match the requirements of the terms of
reference as given in Annex 1. The research questions formed the basis of the Evaluation
Framework1 that specifically outlined the approaches to inquiry and analysis in answering the
questions.
The evaluation used a Cross-sectional Study Design that employed a Mixed Method Approach,
which relied on the use of both quantitative and qualitative methods (though largely skewed
towards the latter) in drawing data from programme beneficiaries, programme implementers
and other stakeholders at district and national level. The district level stakeholder
representatives included community members and their leaders as well as local health
professionals whilst consultation at the national level included MoHCW officials, ZAN,
HOSPAZ, UNICEF, WHO and CCM representatives.
The data obtained through the various data collection methods collectively contributed to
providing the comprehensive picture relating to the performance of CHWs, the program and
its contribution to desired health outcomes. The analysis of qualitative data (from primary and
secondary sources) was largely based on content analysis and use of the grounded theory for
the analysis and interpretation of qualitative data. Similar issues emerging from the different
sources of information were grouped together by thematic area and analyzed to establish key
conclusions of the analysis.
2.2 Data collection
2.2.1 Secondary data review
The primary data collected was preceded by a review of the GF target disease program’s
secondary data in order to assess effect and change over time. Secondary data reviewed
included programme and national data as well as reports drawn from the National Health
Management Information System (HMIS), specific department databases (Malaria Control
Programme, AIDS and TB Unit), and the CHBC Programme database for the period under
review. Analysis of secondary data generally focused on programme data on reach, access,
utilisation and finance.
2.2.2 Primary data collection
Sampling methodology
Two districts, Makoni and Chegutu were randomly selected for field visits aimed at obtaining
district level data primarily from the community members, the CHWs and health
professionals. It is important to note that due to low coverage in the primary data, the findings
based on the CHW interviews and FGDs are largely indicative and not necessarily
representative of all CHWs. However, due to the inclusion of secondary data including key
informants at national, provincial and district level, the findings of the evaluation are inferable
to the whole Global Fund supported CSS programme in Zimbabwe.
1
See Annex ….
11
Fieldwork
The fieldwork was guided by a detailed protocol and was characterised by field planning and
scheduling, community and stakeholder involvement in the data collection, a focus on
quality assurance and observance of ethics in research.
The evaluation team managed to conduct 12 Focus Group Discussions (FGD) in all, 7 in
Chegutu District and 5 in Makoni District. While most of the discussions held in both districts
involved mostly the VHWs and CBHCs, at Makoni Rural Hospital the participants comprised
mainly community leaders due to the logistical problems encountered in reaching the VHWs
and the CBHCs (see Annex 9 for details of the people met). In all the discussions and interviews
conducted the consulting team endeavoured to ensure that all the participants were exposed
to all the evaluation questions.
Primary data was collected by way of FGDs with CHWs and community members; as well as
Key Informant Interviews (KIIs) with stakeholder representatives using guides and data
collection instruments specifically designed for the purpose. The FGDs and other processes
were augmented by the use of Participatory Reflective and Appraisal (PRA) Techniques
including the Most Significant Change approach in documenting change. Data extraction was
employed to draw relevant secondary data for analysis from the various data sources.
Key informant interviews
With the aid of a KII Guide developed for the purpose, the evaluation obtained information
from the key informants selected at the various levels. The guide comprised a list of questions
and prompts compiled under specific thematic areas of inquiry that were structured to guide
the interviewer in facilitating a discussion with the informant. The primary purpose of the KIIs
was gather evidence on the informants’ perceptions and opinions on the specific issues
discussed as well as to triangulate the information obtained from other sources.
Focus group discussions
Discussions were held with representatives of beneficiary communities, CHWs and
community leaders in order to establish their perceptions, opinions and attitudes on the
effectiveness of the programme, strengths and weaknesses as well as the change brought about
by the programme to date. FGD Guides were used to facilitate the discussions and these
comprised a list of open-ended questions for discussions combined with Participatory
Learning and Action (PLA) exercises to facilitate respondents’ participation in-line with the
focus areas. The PLA exercises included:



the Battery Technique;
the Proportional Piling Technique; and
a strength-weaknesses-opportunities-threats (SWOT) analysis.
The FGDs were complemented by observation of the work that the CHWs have been
conducting. This served to triangulate the information drawn from other approaches.
2.2.3 Data analysis
Trends for routine HMIS and program data were plotted and comparisons made over time.
Output level data such as the number of trained, active and supported CHWs, caseload and
coverage and contacts over specified periods as well as change in knowledge and skills levels
was obtained to ascertain the effectiveness of the program. The financial analysis included a
review of the Budget versus Work plan, and Expenditure versus Set targets.
12
2.2.4 Limitations of the study
In reading the findings of this study it is important to take note of the limitations that were
encountered by the consulting team, namely: study coverage and sample size; non-existence
of control sites; and, the non-availability of data on CHWs in the official health sector
management information system.
Study coverage and sample size
The number of provinces, districts and sites covered in the primary data collection for CHW
data is not adequate to provide inference at the national level. However, this data was very
useful in shaping the consultations with national level stakeholders and in guiding the
secondary data extraction and analysis. The primary data provided a good indication of what
is actually happening on the ground regarding the CHW activities, performance and
challenges.
Non-existence of control sites
The evaluation design was initially intended to carry out a comparative analysis of
performance and health outcomes at GF funded sites and non-GF funded sites. This design
was based on the understanding that within the districts there could be wards and facilities
that have not received support for VHWs and CHBCs. The reality however is that the resources
and support for CHWs (particularly the VHWs) was spread across the districts such that all
facilities would have at least one VHW trained and supported with an incentive package. This
therefore implied that the comparison as initially intended by the consulting team was not
possible due to contamination.
Non-availability of CHW data in the official health sector management
information system
Data relating to the work and performance of CHWs has not been captured in the HMIS. An
assessment of performance, analysis to establish attribution and the extent of significance of
the CHW contribution to health outcomes could therefore not be conducted in the absence of
such data. The data on CHBC based on the CHBC Program database was useful in providing a
picture of the work done by CHBCs but could not be directly linked with data in the HMIS or
OI/ART databases.
In the absence of adequate CHBC data, the disease specific service provision and utilization
data was used as a proxy for gauging the influence of the work of CHWs on the utilization of
services. Community perceptions of change and the accompanying factors were also sought to
understand the national trends derived from secondary data analysis.
13
CHAPTER 3: FINDINGS- PROGRAM DESIGN
3.1
Programme relevance and quality of design
The CSS program is a relevant and appropriate intervention. There is consensus amongst
stakeholder representatives that the CHWs serve to bridge the gap between the communities
and the formal health care system. The GoZ acknowledges the important role played by
communities in improving access to health care services in the country. Since 1980 it was
realised that the ability and capacity of communities to participate in health development
activities depends on the decision making space they enjoy and the degree to which they
control the resources available to them to carry through those decisions. It is in view of this
fact that the health services sector has placed the active participation of communities in
facilitating service delivery on the health development agenda.
Since 2000 Zimbabwe has experienced a decade of economic and social decline resulting in
the exodus of skilled personnel and the deterioration of infrastructure which have
compromised efforts by the government and its development partners in providing universal
access to basic health services and the combat of HIV/AIDS, TB and malaria. The CHW
programme was revitalised to reverse the adverse impact of a weak health delivery system and
to improve access to health services at the primary level. The CHW cadre was not new to the
communities and the CSS program was a revitalisation of the Village Community Worker
introduced in the early 1980’s. The program as a whole is in-line with the provisions of the
national health strategy as well as the strategies of the individual disease components
supported under the GF grant, namely HIV/AIDS, TB and malaria.
3.2 Evidence of incorporation of community-based approaches into
program strategies
3.2.1 The national health strategy
The National Health Strategic Plan for Zimbabwe 2009 to 2013 recognises that good health
and quality of life do not derive only from the health sector, but are influenced by a myriad of
other factors which are outside its direct influence. It focuses on three key result areas namely:



improving the health status of the population;
improving the quality of care; and
strengthening health systems.
The mission statement is anchored on, among others, the Primary Health Care (PHC)
approach as a leading strategy for health development, developing innovative and new
approaches in management and delivery of services in ways that enhance access, community
satisfaction and local accountability, widening participation and the awareness of social
determinants of health. The plan aims to keep as many people as possible in good health in
the community through health protection, health promotion and disease prevention strategies
before providing quality care at various levels of specialization.
The new strategic focus hinges heavily on community participation as one out of the five pillars
of the strategic plan. The strategic plan has 32 goals depending on 138 objectives for their
achievement. However, 7 of the goals, and altogether 58 (42%) of these objectives cannot be
adequately and effectively implemented without involvement of the CHW through community
approaches.
The strategic plan also provides for the cross cutting health systems strengthening areas that
include service delivery, health information, financing, medical commodities supplies and
logistics, as well as leadership and governance as critical success factors. This is done in the
14
overriding spirit of the three ones (i.e. one strategic plan, one M&E framework and one
coordinating mechanism), whose execution and strategies to achieve long term health impact
are well documented in the different sections of the strategic plans. This further reinforces the
relevance and appropriateness of the CSS, a timely and supportive intervention for the other
disease components.
3.2.2 Program strategies
The Zimbabwe National HIV and AIDS strategy
The national thrust to strengthen community participation and involvement in the provision
of health care services has been taken up at disease component level. One of the key principles
of the ZNASP is the need to strengthen a multi-sectorial approach in the fight against
HIV/AIDS. The CHBC component has been identified as key in the ZNASP. The national AIDS
policy recognises CHBC services as an extension of the health care delivery system that has to
be fully developed and supported as an essential component of the continuum of care for
PLWHA.
The national plan for the provision of ART (2008-2012) recognises the role played by
communities in ART follow-up. The plan also recognises the need to harmonise CHW training
materials into a national standard CHW training program. It is acknowledged that individuals,
families and communities play an essential role in providing care to clients and thus their
involvement is considered very important in the fight against HIV/AIDS.
The National Tuberculosis strategy
The national TB strategy (2010-2014) recognises the complementary role played by
communities, CBOs and NGOs in providing TB services. The range of services provided by
these partners include patient support, including direct observation of treatment (DOT),
patient, family and community TB related education, supporting case finding activities and
lobbying for greater government support for TB control. The strategy while acknowledging the
weak implementation of community TB care recognises the existence of the CHBC program
for HIV/AIDS as an opportunity for enhancing the community TB care service offering.
The strategy recognises that community participation in health care delivery is a key
component of the PHC system. The involvement of the community should enhance case
finding and case holding thereby contributing to improved program outcomes. The NTP will
promote and strengthen community DOTS in all districts of the country through:

development of policy, guidelines and training materials on community DOTS,
including the TB patient charter;

training of stakeholder representatives on community DOTS;

introduction of phased implementation of community DOTS; and,

provision of supportive supervision and monitoring of community DOTS.
The National Malaria Control strategy
The National Malaria Control Program also recognises the value and importance of the
communities in program implementation. The NMCP coordinates program implementation
through the Provincial Medical Directors (PMD), who in-turn are supported by the Provincial
Health Executive (PHE). At the district level (the implementation level), the District Medical
15
Officer (DMO) is responsible for malaria activities and coordinates with the Rural Health
Council (RHC) staff, Ward Health Teams (WHTs) and CHWs. There are clear communication
and reporting lines through the administrative levels in the health system.
In-line with the universal access to the malaria interventions, the strategy seeks to ensure that
the new treatment policy is cascaded down to the community based health workers after
training on use of ACTs and RDTs. The NMCP endeavours to take all the necessary steps to
ensure that the new anti-malarial drug, coartemether, which is registered as a prescription
drug is delisted to enable its dispensing at community level. Other issues relating to the use of
RDTs and the handling of blood samples by the community-based health workers will also be
addressed during the period covered by the strategic plan.
3.3 CHWs participation and contribution to HIV, TB, malaria and
MNCH programs
3.3.1 CHWs participation in the programs
There are two main categories of health workers found in the communities, namely: the VHWs
and the CHBCs. The VHWs are managed by MoHCW whereas the CHBCs are managed by
NGOs and CBOs. The CSS Program provided support to both sets of CHWs and therefore their
impact on the specific program components is worth evaluating. In addition, there are some
community volunteers who are engaged by the individual program components for specific
time-bound health related activities. These volunteers include: those involved in distributing
condoms; the behaviour change facilitators; those involved in distributing treated nets; and,
DOTs observers. Due to the ad hoc nature of their involvement, the volunteers were not
involved in the evaluation study.
The Village Health Worker
The VHWs are ordinary members of the community who volunteer to render community
health services, serving as the link between the clinic and the community. VHWs work as parttime volunteers carrying out health related activities such as educating and motivating the
communities in the prevention of both communicable and non-communicable diseases as well
as other health conditions in the community. The criteria used in identifying and appointing
VHWs places emphasis on the following attributes:
–
ability to read and write;
–
maturity, stipulating that one must be at least 25 years of age;
–
permanent residence within the community served. Unmarried males and females are
excluded from the selection of VHWs since they are perceived to be most susceptible to
migration pressures;
–
demonstrated interest in community health work and developmental issues;
–
a respected member of the community;
–
good public relations and an approachable personality;
–
ability to educate and motivate other community members to take up and maintain good
health practices.
16
This selection criteria is outlined in the VHW Handbook used by the MoHCW and is therefore
available for use by the communities and their leadership in guiding the process identifying
suitable candidates. VHWs work between 4 to 7 half-days a week although when there are
disease outbreaks or during national immunisation campaigns they work 4 to 5 full days a
week as demand for their services tends to increase. The VHW are supervised by the staff from
the clinic they are affiliated to.
The Community and Home Based Caregivers
Community and Home Based Caregivers (CHBCs) are members of the beneficiary
communities serving as a link between the clinic and the community but primarily focusing
on providing care and support services to people living with HIV/AIDS (PLWHA). They work
as secondary caregivers to patients afflicted by HIV/AIDS related illnesses usually after they
have been discharged from the hospitals. Their work involves maintaining regular contact with
the patients and their primary caregivers, undertaking such roles as providing care and
support to the client and training family members in how to best provide psychosocial support
and palliative care to the patients. They are trained in home based care provided by different
NGOs for PLWHA in their communities. They are supervised by the NGOs that train and
support them. Most community caregivers volunteered to work, while a few were selected in
the same way as VHWs.
3.3.2 Contribution of CHWs in disease programs
The responsibilities of VHWs and CHBCs are similar, only differing in that community
caregivers’ have generally been confined to providing HBC and support mainly to PLWHA
whereas the work done by VHWs is all encompassing going beyond focusing on HIV/AIDS
related illnesses. The responsibilities stated provide ample evidence that CHWs participate
and contribute to the fight against HIV, TB and malaria (see Table 1).
Table 1: Responsibilities of Community Health Workers
The responsibilities of Village Health Workers (VHWs)
–
To educate the individuals and communities on health related issues, health promotion
and disease prevention for both communicable and non-communicable diseases
(including hypertension, diabetes, HIV/AIDS related illnesses, stroke)
–
Identifying and referring suspected malaria cases to the health facilities for diagnosis and
treatment.
–
To encourage women to breast feed and present their babies for immunisation
–
Conduct follow-up visits and supervision of TB patients on DOTS treatment at community
level
–
Provide information on HIV/AIDS and HBC management and rehabilitation.
–
Support outreach programmes including growth monitoring and providing school health
services
–
Conduct health promotion activities on WASH, ANC, PNC and family planning
–
Collect information, data and maintain a record of members of households receiving and
requiring support and use it for planning purposes
–
Collecting data required for reporting and monitoring and evaluation to the RHC. They
submit reports every month to the clinic using a standardised form.
The responsibilities of Community and Home Based Caregivers (CHBC)
–
Maintaining regular contact with HBC clients and their families providing training to
family members in how to best care for their patients. They also provide physical,
emotional and spiritual support to both the clients and family members
–
Impart practical caring skills to primary caregivers
–
Identifying and referring clients to clinics and other health service providers for VCT, OI
and ART services.
–
Providing health education information on specific topics such as ART, the possibility of
developing TB and how to recognise it, pain medication, nutrition and hygiene
17
–
–
–
–
Monitoring use and adherence to medication
Promoting uptake, use of condoms as well as distributing these and other IEC materials
Community mobilization to discourage the discrimination and stigmatisation of PLWHA
Providing supportive counselling to persons requiring such and encouraging them to
utilise available HIV and AIDS services
3.4 Sustainability of CHW component beyond GF support
3.4.1 Ownership and recognition of CHWs by the community
There are strong indications that CHWs are likely to continue providing services in the
community beyond the period supported by the Global Fund. It has been observed that CHW
programmes are governed and owned by the beneficiary communities. The community plays
a significant role in various aspects of the programme including: the selection of CHWs;
supporting the cadres; as well as, in providing community level accountability platforms, even
though this is not formalised. The community is involved in the selection of the CHWs through
a community voting system based on community-defined criteria. In most of the communities
served there is a critical mass of committed and literate individuals willing to provide the
service. The community also provides a platform (though informal) for accountability as
members through the leadership can also influence whether a CHW is retained or dismissed.
However, the consulting team also noted that due to high levels of poverty, most members of
the communities served do not have the means to contribute towards any significant material
incentive packages that could be offered to the CHWs. The CHWs have been noted to be
motivated by other intrinsic factors that contribute to their retention. For example, there is a
strong sense of ownership and recognition of the cadre by the community. The CHWs
appreciate the receptive nature and willingness to adopt recommendations by members of the
community. It is however important to note that the virtues and focus of CHWs as well as the
extent to which these factors are motivational differs from one individual to another and with
the times. Since these factors cannot be quantified they cannot be relied upon as the basis for
motivating the CHWs. All groups interviewed pointed to the likelihood of compromised
quality of service due to attrition amongst CHWs in the absence of a formal package of
incentives including allowances, uniforms and bicycles. The formalisation of the incentive
package is therefore deemed a necessary component of the CSS programme particularly after
GF support is terminated.
Despite some inadequacies in provision of supplies, incentives, supervision and coordination,
the CHWs have proved a useful bridge between the communities and the formal health care
system.
3.4.2 Funding of CHW program
Government contribution
Since the adoption of the PHC strategy in 1980, the government has played a key role in the
training, support and supervision of the CHWs. The MoHCW has provided the training
venues, tutors and supported the development of the training curriculum for the VHWs. The
recruited personnel have also been provided with kits comprising medical supplies used to
provide basic health care services to the communities. These supplies include painkillers, antimalarial medication, bandages, eye and wound ointments.
In each province and district there are established CHW trainers and “trainers of trainers”
within the ranks of the MoHCW structures. The MoHCW has made it policy that every partner
who intends to support the programme should do so through the existing MoHCW structures.
18
To date, most of the support received from partners has been applied towards funding training
activities.
There has been notable deterioration and in some cases the collapse of basic social services in
the country, particularly during the period 2000 to 2008. As a result, the coverage of key
health interventions in Zimbabwe decreased significantly. Given that this coincided with a
period during which the HIV/AIDS pandemic was at its worst, the country’s performance on
key health indicators show a downward trend between 1990 and 2009.
Against the background of severe economic circumstances and limited fiscal space, funding
the health sector has become a big challenge for the Zimbabwe government. The overall budget
allocation to the public health sector has remained low at less than 10 percent of annual budget
against the agreed Abuja target of at least 15 per cent. In 2011, the MoHCW was allocated per
capita expenditure of $19.7 against a target of $34. The reduction in funding of the health
sector from central government over the past decade has led to the reduction of funding
allocated for the CHW program. An analysis of expenditure records shows that even when
efforts are made to allocate decent amounts to the various budget items the government has
struggled raise the allocated amounts leading a situation where actual expenditure is
substantially less than the budget amounts. Table 2 shows that the Ministry of Finance only
managed to release $420 of the budgeted of $2.3 million in 2009 and $32,912 of the budgeted
$1.0 million 2011. In view of the resource constraints faced by central government, much of
the funding for the health sector has been provided by development partners mainly from
external sources. This trend is likely to continue in the short to medium term and therefore it
is unlikely that the projected budget figures shown in Table2 for the 2012 to 2014 period will
be realised unless there are significant changes in the political and economic fortunes of the
country over the same period.
Table 2: Government budgetary allocation to the VHW programme
2009
Budget
Estimate
($)
2009
Expenditure
($)
2011
Budget
Estimate
($)
2011
Expenditure
($)
2012
Budget
Estimate
($)
2013
Budget
Estimate
($)
2014
Budget
Estimate
($)
2,301,000
420
1,000,000
32,912
870,000
920,000
958,000
Source; Ministry of Finance 2010 & 2012 National Budget
Contributions received from other development partners
Since the adoption of the primary health care approach by government, various development
partners have supported the CHW approach in different ways ranging from funding for
training to the provision of incentives. The renewed impetus to strengthen the community
health systems in response to the 1998/9 cholera outbreak brought in various other
development and technical partners to support the program. After the adoption and adaption
of the initiative by the Global Fund, various partners have continued to support the
programmes in different districts in different ways. Most support has come in the form of
training with some partners also providing bicycles and bags. Some of the partners that have
been active in this regard are UNICEF, WHO, Save the Children, World Vision, Zvitambo,
Goal, UNDP and Merlin.
In 2011, a $70 million multi-donor initiative, the Health Transition Fund (HTF) was created
to support the country’s efforts towards realising the MDG 4 and 5 that are meant to address
maternal and child health issues. The need to strengthen community health systems is
considered a priority area under this initiative. The program has allocated a budget of
$4,193,000 towards the review of the VHW training manual taking into account the following
19
issues: current HIV/AIDS information on maternal, new born and child health including
PMTCT, IMNCI; reorientation of VHW trainers using the revised VHW training manual;
training of 5,000 VHW; procurement of VHW utility kits; payment of allowances for 5,000
VHWs; recruitment of a full time VHW coordinator; and, training of Environmental Health
Assistants (EHTs).
CSS funding gap analysis
Table 3 shows the funding gap up to the end of 2014 taking into account the funding available
or committed to the CSS programme by government and other development partners. The
total funding requirement is estimated based on the need to support about 17,000 CHWs as
indicated in the HTF. The needs include annual training, provision of allowances and the CHW
kit. Government contribution to the program is currently estimated at less than 6 per cent of
the total requirements at the moment.
Table 3: CSS funding gap estimates
Funding source
GoZ
GF HSS grant (Allowances +uniforms for 11260 CHWs)
GF HIV grant (Training of community cadres in linkages
between FP and HIV service delivery
GF TB grant (Training of community health workers on
community TB care and DOT)
GF Malaria grant (Supervision by health care workers of
CHWs of ACT and RDT use)
GF Malaria grant (Training of community based health
workers in malaria prevention and control methods)
HTF ( training, allowances and CHW kits for 5000 CHWs)
2012
870,000
2,124,987.38
47,900
Total available
Total Need
Funding Gap
Year
2013
920,000
2,182,094
47,900
2014
958,000
2,182,094
-
68,900
90,000
120,000
90,000
4,193,000
92,840
No data
92,840
No data
5,200,900
12,981,200
7,780,300
3,431,734
12,981,200
9,549,466
3,322,934
12,981,200
9,658,266
Source; 2011 National budget, GF Phase 2 grants and the HTF Year 1 work plan
It is clear that GF funding for the programme has been fragmented with allocations meant to
support the training of CHWs spread across all the grants. It would be more effective and
efficient for the Global Fund to provide funding for the component through a single channel,
the HSS grant.
The gap analysis in Table 3 clearly shows that the financing requirements for implementation
of the identified strategies will be heavily dependent on support from development partners
in the short to medium term. It is however encouraging that the prospects for the sustainability
of the initiatives are good because of the existence of a conducive institutional framework. The
CHW programme has been implemented in-line with the existing MoHCW structures with the
active involvement of community structures. While the provision of funding from the central
government is currently well below the required levels it is envisaged that this situation will
improve as the country’s economic fortunes improve with the stabilisation of the political
environment in the medium to long term. In addition, the sustainability of the CHW initiatives
is assured given that most of the technology applied is well known and it is envisaged that the
approach to implementation will be improved gradually through continuous learning,
documentation, dissemination and sharing of best practices.
20
CHAPTER 4: FINDINGS - PROGRAM IMPLEMENTATION
4.1
Adherence to work plan
4.1.1 Timeliness of implementation
The training of CHWs was implemented on time where all the initial training was completed
in Year 1 of the grant as planned. However, not all incentives and uniforms were provided for
during the planned period. Allowances for MoHCW were paid up to quarter 6 (June 2011). No
allowances were paid in quarters Q7 and Q8 due to non-disbursement of funds from Global
Fund. Payment of allowances was also erratic due to poor timeliness of acquittals from lower
levels to national levels. Disbursement decisions by the PR under the grants were based on an
80% acquittal threshold. It was in many cases difficult to reach the threshold since the
allowances were not paid monthly but at the end of the quarter. The funds for the allowances
were later disbursed in Q9 and Q10.
In the workplan, both sets of uniforms were to be provided by Q7. However, the last batch was
paid for and delivered in Q10, April 2012 due to delays in disbursement of funds.
4.1.2 Completeness of implementation
The figures cited under the HTF show that the national target for the CHWs has been
estimated at 17,000. Although the CSS program target was set at 11,160 CHWs a total of
11,514 CHWs were trained. However the additional support provided under the programme
(uniforms and allowances) was meant to cater for only 180 CHWs in each district. As a
result, there are many reported cases of people who benefited from the training who are have
not been allocated uniforms and are not receiving the allowances.
The ideal training programme for VHWs should cover a period of 20 weeks comprising 8
weeks of classroom training, 8 weeks of field practicals and 4 weeks of additional theoretical
training. Due to funding limitations, the GF supported programme provided resources to
cover three weeks of training for VHWs, with the entire 8-week curriculum crammed into
the shorter period.
Lack of provision for translation of the curricula to local languages meant that some of the
training materials had to be translated by trainers during training, which may have resulted
in limited uptake of the knowledge and misinformation at worst. Modules on the prevention
and treatment of TB and Malaria were reportedly understood better as these two diseases have
been endemic in the community for a much longer period. Variation in performance amongst
the various cadres across the different duration of training exposures was not measured in this
evaluation, but there is a high likelihood their performance abilities may differ depending on
the nature and duration of training.
4.1.3 Delivery approaches
Training was conducted by designated nurses at designated places at local level. Selection of
VHW candidates was done at community level. The trainers used the available training
curriculum. Coverage of the curriculum was limited to the available 3 week period. For the
CHBCs the implementing CBOs in conjunction with the local NAC structures identified
volunteer candidates. These candidates were trained for a period of two weeks. This is the
designated period for training CHBCs using the existing curriculum.
The incentive, $15 per month per person was limited to 120 VHWs and 60 CHBCs per district.
According to the workplan, payments of the incentives was to be done monthly. However,
during implementation the PR in consultation with the SRs agreed to make the payments
21
quarterly to ease logistical pressures. This was supported by the CHWs who felt that it was
more economically/sensible to receive the cumulative amount than the monthly allowance.
4.1.4 Adherence to national guidelines and targets
The training that was provided to CHWs was in-line with the national curricula for both the
VHWs and CHBCs. While the curriculum for VHWs is expected to be delivered over a period
of 8 weeks, the GF only provided funding for a three week training period. The two week
training period required for CHBC training was adequately provided for under the grant.
Although the general national guideline for VHW coverage is 1 VHW per 100 households there
is no well defined number of VHWs or CHBCs required in the country. Coverage in the field is
going to as high as 1 VHW to 500 households. The Health Transition Fund estimates the
required number of CHWs at 17,000. The CHW programme had planned for 11,160 but then
trained 11,514.
The VHW programme in the country is considered voluntary and therefore no allowances were
provided for. However, during the design of the CHW programme there was an initiative to
improve the incentives received by the CHWs in appreciation of the work they were doing. It
was at this point that the $15 per person per month was introduced. This has since been
included in the draft Village Health Worker national strategy.
The standard package for the VHWs includes 2 uniforms amongst other provisions such as
bandages and pain killers while that of CHBCs include a CHBC kit. The CHW programme
provide for the uniforms as well as the CHBC kit but did not provide the VHW complete
package.
4.2
Capacity of CHWs to implement planned interventions
4.2.1 Training requirements
The CHWs that participated in the PLA exercises reported that, prior to the training, their
knowledge levels were very low particularly in the areas of TB, HIV and AIDS and malaria
(estimated at between 10 to 20 percent). The reasons for this low level of knowledge were that
they felt they only had superficial and out-dated information on the health issues or diseases
before, with some even confessing that their interpretation of the little information they
possessed presented potential harm to their family and community. A particular example that
was cited related to the use of cow dung in the management of burns. The main area of
significant improvement cited by CHBC caregivers was their ability to provide palliative care
to PLWHAs and their families. One of the nine modules of the harmonised CHBC Training
curriculum is focused on palliative care. The training itself was reportedly focused on palliative
home-based care. As such the caregivers felt they were now better able to deal with the other
emotional, spiritual and psychosocial needs of their clients in addition to physical pain issues.
The CHBC caregivers who received the training demonstrated a good understanding of the
concept of palliative care and home based care in general and indicated that despite the decline
in terminal cases requiring end of life care amongst PLWHA the skills acquired are applicable
from the onset of one’s illness and extend to other non-communicable diseases including
cancer, stroke and heart related illnesses. In the absence of direct observation and records of
skills assessment, this review depended on the caregivers’ account and key informants
including HOSPAZ and ZAN to establish the extent of change in skills amongst the trained
(see Annex 6, for more details). Discussants and interviewees provided a communal opinion
that there was demonstrable improvement in care giving skills amongst the trained. However,
they also emphasised the need for refreshers courses and continuous mentorship as well as
extending the training to the management of other common illnesses.
22
4.2.2 Appropriate skills-mix
The skill acquired by the CHW acquire determined by, among other things, the training
received. The CHBC were trained according to the full curriculum designed by the MoHCW
and therefore they were adequately equipped for the intended purpose. On the other hand, the
training given to the VHWs was delivered in 3 weeks even though the full curriculum should
ideally, be covered in at least 8 weeks. Although different partners have augmented the
training to various levels, there still remains a significant gap in the skills of the VHWs to fully
provide the requisite services at optimal level. This skills gap has further been widened by the
introduction of new focus areas on maternal, new born and child health issues which are the
focus of the HTF. The VHW curriculum is currently under review to incorporate this
dimension. Additional training will be required to equip the VHWs with the appropriate skills
in this regard. Even when the CHWs receive the full initial training, subsequent refresher
training will be required to continuously match their skills with new requirements.
While the CHWs are expected to do more of preventative work than curative, there is a general
feeling that these cadres can be effectively involved in some initial stages of the curative
process. Frequently mentioned areas include sputum collection as well as testing for malaria.
The MoHCW has since started training CHWs in the use of RDTs to facilitate treatment of
malaria in the communities. These skills should be considered for inclusion during the review
process of the curriculum.
4.2.3 Adequacy of supervision of CHWs
The success of CHW programmes hinges on regular and reliable support and supervision.
Continuous supervision diminishes the sense of isolation that CHWs usually experience in the
field and helps to sustain their interest and motivation to do their assigned tasks.
In the areas visited, there was no standard checklist used to guide the supervision of VHWs.
The interaction of the VHWs and their supervisors was only limited to monthly meetings
which was not adequate to mentor the VHW in performance improvement. In some areas, the
nurses did not have adequate information on how and when the incentives were provided.
This posed challenges in supervision as the VHWs felt their supervisors were letting them
down. It was also noted that there was limited on the-job supervision because of transport
challenges. EHTs in some wards were providing support and supervision to the VHWs because
of their regular contact and access to motorcycles and bicycles. However, transport still poses
a challenge as the vacancy rate for the EHTs is high.
Lack of systematic involvement of cadres from other MoHCW departments in CHW
supervision was said to be due to exclusion of these departments during training of ‘Training
of Trainers’ on the CSS programme which involved nursing personnel only. It was however
later realised that the VHW cadres would not be adequately supervised without involvement
and guidance from other departments. Currently other specialised departments, including the
Departments of Community Medicine and Epidemiology respectively are now involved in the
training of the cadres.
The supervision of CHBCs is mainly provided by the NGOs and CBOs in addition to their
monthly meetings with the health professionals. For example, district personnel from FACT
in Makoni District were reported to conduct supervisory home visits with the community
caregiver supervisor (also a CHBC and community based) to check on patient care. The
approach, though realistic in addressing coverage, was observed not to offer adequate
mentorship support to each of the trained CHBC caregivers, as there was no evidence of group
mentorship or additional follow-up to the other trained individuals. The monthly meetings
with the health professionals are largely feedback oriented in which the CHBCs share and
23
discuss their report with the health professionals with minimal skills based supportive
supervision.
4.2.4 Adequacy of logistical support
Every VHW affiliated to the nearest health facility in her/his catchment area, and is expected
to collect/replenish basic supplies whenever there is a need. The basic supplies include pain
medications such as paracetamol, eye ointment, vitamin tablets, betadine and bandages.
During the field visits it was established that some of the VHWs have not received a
replenishment of their supplies for a long time due to the unavailability the necessary
consumables at the nearest health facility. Of the 12 VHW teams assessed, 11 had stock-outs
of the basic medications and medical supplies for their work. Dumbamwe clinic in Makoni
district was the only facility, which reported having recently provided some supplies to the
VHW team, but again they reported having had a stock-out from January to March 2012. In
most rural clinics, the VHWs would only receive supplies if their local clinic had these in
excess. Therefore the VHWs could not do their job properly and this adversely affected the
community’s perception of their effectiveness in delivering health services due to the lack of
supplies.
4.3
Coordination and communication between organizations
As noted earlier, the VHW programme was revitalised at the height of Zimbabwe’s socioeconomic crisis to deal with the cholera outbreak as the health system was not capable of
reaching out to every corner of the country. During this crisis, as in others, the UN agencies
restructured themselves to support the country response. With the WHO in lead, coordination
of the VHW activities was more intense, sometimes being as frequent as bi-weekly
coordination meetings attended by all partners and representatives from the provinces and
the districts. Reports from field activities were read and strategies agreed to deal with the most
crucial issues expeditiously. That way, all people were involved and informed on the goingson, and all levels of management, the provincial, district and local health facility levels were
kept informed and involved.
In order to achieve a more holistic and better capacitated community cadre, there is a need for
involvement of the nursing, environmental health and health promotion sections within the
MoHCW. This would involve participation in development of training curricular, provision of
guidelines and ensuring adherence to the set standards of community health service delivery.
It also entails monitoring of progress through support supervision, sharing field reports and
arriving at consensus in taking the necessary corrective measures. This kind of coordination
needs to be institutionalised within the MoHCW, and replicated at the provinces and districts,
the levels responsible for decentralised health service delivery.
Vertical coordination
The evaluation found that at each health facility there was a nurse in-charge of the CHW who
reports to the District Nursing Officer (DNO) in-charge. The DNOs report to the PNOs who in
turn report directly to the Director on Nursing at the National level. However this seemed to
be more or less a vertical approach and a preserve of the nursing department as the reporting
lines did not include the Health Executives and their teams at the district and provincial levels.
At the national level the reports and operational management of the CSS programme fell
directly under the Director of Nursing with little evidence of involvement of the Health
Promotion and Environmental Health departments. Naturally representatives of the CSS
programme were required to attend the CCM Health Systems Strengthening sub-committee
meetings both to share their progress reports and get guidance on the way forward but
24
evidently this was not happening as they hardly attended these meetings and their progress
reports were rarely shared at these meetings.
It was also observed that the available training materials were heavily biased towards nursing
due to lack of involvement of all the necessary stakeholders such as Health promotion,
Environmental health and other departments in development of crucial VHW training
curricula, manuals and materials.
Provincial and district coordination
The limited awareness of the CSS programme activities by the personnel at provincial and
district levels had its toll on the effectiveness of the programme with no standard VHW
guidance materials or mechanism for involvement in support supervision. At the rural health
facilities the face of the health care system and the nearest centre for support to these VHW,
the nurses’ in-charge of the CSS programme were not even aware of the schedule for payment
of incentives to the CHWs. There was lack of prioritization of support visits to the working
places of the VHWs, let alone involvement of the EHT whose work is community based and
they therefore needed to work closely with the CHWs to support over 75% of their community
work. There was also lack of aggregation, analysis and onward transmission of VHW reports
from health facilities which brings into question the design of the overall project, as
performance of the VHWs is not monitored or reviewed at any level of the health system except
for that of the CHBCs. Nobody seemed to be aware of the strategic direction the CHW
programme was taking.
When contacted some of the nursing staff said they actually held several coordination
meetings (i) national level meetings with PNOs, (ii) PNOs visiting districts to assess the VHW
situation, and (iii) the DNO and other nurses visiting the health facilities to assess the VHW
situation at the health facilities. Reports from these visits were sent directly to the Department
of Nursing and not shared at all the levels.
Cross departmental coordination
The Directorate of Environmental Health personnel expressed ignorance of the activities
implemented under the CSS programme although they felt that they should be closely involved
since 75% of the VHW’s work is preventive and therefore heavily dependent on support and
guidance from the Environmental Health Department. They said supervision visits to the
VHWs should have been a joint effort between the EHTs and the nurses from the health
facilities so that all aspects of the work of VHWs could be supported to ensure performance
improvement. They attributed the lack of support CHW supervision visits by nurses to the
predominantly preventive work the VHWs did within the communities which had very little
to do with nursing. There were fears the VHWs were only functioning at less than half their
capacity as the technical guidance on preventive services such as hygiene, nutrition, food
security and related issues were not being emphasised due to marginalization of the
Environmental Health Department whose structures are present country wide though some
are currently not on the Government payroll.
4.4
Facilitating and inhibiting factors in implementation of CHW programme
4.4.1 Facilitating factors
Community participation, involvement and ownership
CHW programmes are governed and owned by communities. The community plays a
significant role in the selection of CHWs as well as in providing community level accountability
platforms. CHWs were accountable to the communities that selected them. The CHWs in most
25
wards appreciated the receptive nature and taking on board recommendations they gave to
the community.
Training
There is a broad based training curriculum developed by the MoHCW for the VHWs and
CHBCs to facilitate their integration in their roles. There is an integrated VHW training
curriculum and the harmonised CHBC training curriculum (see Annex 4&5). The complete
curriculum developed for VHWs training should take them a minimum of 8 weeks of training.
Ideal training will involve 8 weeks of classroom training, another 8 weeks of field practicals
and a final 4 week period of theoretical training. The provision of training to the CHWs was
seen to enhance the knowledge, skills and overall capacity of the cadres in performing their
work.
Utilisation
The CHW are recognised and utilised by the communities as evidenced by reports made by
community leaders, reports submitted to their respective CBOs and the RHC on monthly basis.
The reports detail the contacts made with the communities on various health related issues.
Community members know when and how to approach CHWs when the need arises. Some of
the proxy indicators that the CHW play an important role include:

increased number of people referred and visiting the nearest health facility for medical
attention for various ailments. This indicates that people get to them first before visiting
the health workers;

reduced number of home deliveries;

increased number of women visiting the ANC within the 3 months of pregnancy;

increased knowledge levels among community members about certain diseases such as
Cholera, HIV and AIDS, TB and Malaria prevention;

reduction in stigma and discrimination of PLWHA and even in the general burden of
HIV; and,

increase in coverage of immunisation.
There was a reported decrease in the number of HIV/AIDS related deaths and an increased
uptake of partner HIV testing and ART treatment in the areas. The number of individuals
undergoing HIV testing had gone up as the CHWs encourage partners of pregnant women to
seek the service. This is a contribution to conforming to the Zimbabwe National HIV and AIDS
Strategy (ZNASP) promoting multi-sectoral approach to the fight against the HIV epidemic.
Reduced HIV/AIDS related stigma and discrimination was reported. The CHWs are also
providing medical and psychosocial support to chronically ill patients in the communities.
Follow up of TB patients at community level was said to have improved. Improved TB
treatment outcomes were reported, with an increased identification of suspected Multi Drug
Resistance (MDR) cases. More positive cases of suspected malaria were being identified in the
community compared to previously where there was total reliance on nurses at facility level.
It was reported that there were less false negative malaria cases identified than before at the
facilities. The contribution of the VHW cadre was through education and promotion of the use
of insecticide treated nets (ITN’s). Mashonaland West Province was the first to train VHW
cadres on the current Malaria drug regimen. Manicaland reported that in 2011 they had no
reports of malaria deaths with only a few complications.
26
Monitoring and evaluation
There is a standardised recording of cases for the CHWs. The VHWs’ reports are mainly based
on the activity reporting whilst the CHBC caregivers record both case registrations and the
activity reports. The difference could partly be related to the nature of the VHW work, which
is largely community wide rather than case based. However, VHW case registration would still
have been appropriate for the specific diseases such as malaria, diarrhoea or the minor ailment
cases they deal with.

Village Health Workers
The VHWs’ have a newly introduced reporting format. The reports provide a summary of their
activities and client contacts disaggregated by diseases and programme areas such as
immunization and nutrition. VHWs submit the reports monthly to the Nurse-in-Charge at the
nearest Rural Health Centre. The extent to which the reports are reviewed and analysed by the
health professionals and VHWs was observed to be unsystematic varying from facility to
facility and largely driven by the initiative of the team manning the facility. Some health
professionals interviewed in this review noted that the VHW reports had been useful in
flagging disease outbreaks in the community.

Community Home Based Caregivers
The CHBC caregivers register their cases using a Case Registration Form whose statistics are
collated into a Monthly Reporting Form. In some wards, CHBCs were not submitting their
monthly reports to the local clinic and only submitted to the NGOs that trained them. The
CHBC reports are discussed during their monthly meetings with the local health professionals.
These meetings are held separately from those of the VHWs. Unlike the VHW reports, a
caregiver supervisor keeps the CHBC reports. The reports are submitted to the parent
organisation (usually NGO or CBO) where they are tallied and submitted into the national HIV
and AIDS M&E System/CRIS Database through the National AIDS Reporting Form (NARF).
Data for the CHBC component funded by the Global Fund programme is consolidated at
District, Provincial and National level through a programme database managed by the SubRecipient HOSPAZ.
Incentives
The Global Fund (GF) is providing funding for a monthly allowance to the CHWs of $15. This
amount is accumulated and disbursed quarterly. The allowances disbursed through the
MoHCW are subject to an administrative levy of $1/month for each VHW paid. As such, the
quarterly allowance received by the VHW was $42.00. The CHBCs paid through ZAN receive
the stipulated $15 per month without any deductions being effected.
It emerged that partners were providing different forms of incentives to the CHWs in different
areas i.e. bags, t-shirts, money and other groceries. The irregularities in receiving the
allowances were demotivating on the part of CHWs. The two districts visited had each more
than 120 VHWs trained while only 120 had been budgeted to receive the monthly allowance
from GF.
In Chegutu, the district authorities were distributing the allowances evenly while in Makoni
the additional CHWs were placed on a waiting the list. The latter was seen to have caused some
disharmony between the CHWs receiving allowances and those not receiving even though they
were doing the same job. At Dumbamwe Clinic, Makoni district, there were four village
community workers and four VHWs supporting the clinic. Only two of the VHWs were trained
under the GF, and therefore receiving allowances. Whilst the others recognise themselves as
being on a waiting list for receiving both training and allowances they said they were still
27
committed to the good cause of their job, but nevertheless they also had essential needs that
needed to be addressed by the health authorities.
To compound it all, other implementing partners would come into an area and provide
incentives for CHWs for a few months and then leave without coming up with a good exit
strategy which would ensure continuity of the programme.
It was however reported that incentives for the CHBC’s were more regularly received, and were
supported by other partners, and constituted more additional items over and above a monthly
allowance of $15 per month. The community and other stakeholders recognised the VHW as
a cadre that had more responsibilities than a CHBC, which was reflected even in the selection
criteria where literacy skills were highly emphasized in VHW selection compared to CHBC’s.
The incentive level for VHW’s may therefore have been set at inappropriate levels, much on
the lower side in this regard.
Retention
Attrition of CHW was noted to be low, mainly due to death of the members. In Chegutu district,
after 157 VHWs were trained by end of 2010, only 7 were lost by the time of this evaluation.
The VHW cadre has remained available to undertake their duties whenever necessary despite
the on – off nature of the VHW programme. Many VHWs currently operational were first
trained in early 2000 – 2002. Although the incentives play a part in motivating the CHW to
remain committed to do their work, the major motivator was noted to be the passion to work
in the interest of the community. Speaking generally the CHWs confessed there are other extra
advantages which seemed to override the incentives as the motivator namely:

the fact that they are the first to know of any new health related information before other
community members gave them courage and enabled them to utilise the information
within their immediate and extended families before they reach the larger community;

the VHW position provides opportunities to learn and be recognised in the community.
It provides them with a level of invaluable social status;

abundant hope – although the incentives are not consistently provided the VHW
remains hopeful that they will come. This hope is also supported by their awareness that
VHW is not a full-time paid job for which remuneration would be expected on a regular
basis;

as promoters of health related issues, they also benefit from promotional materials such
as hats and t- shirts;

self-gratification in providing help in the community.
Relationship with the formal health system
There is positive indication of integration of the community system into the health system as
evidenced by the linkages with the local institutions through supervision and support by
local health professionals and reporting at the local facilities. Both the VHWs and CHBCs
meet with the local health professionals on a monthly basis during which they submit their
monthly activity reports, share their experiences and challenges as well as receive new health
information essential for their day-to-day work.
4.4.2 Inhibiting factors
Inadequate training
28
Due to funding limitations, different partners support the training to different extents. While
the Global Fund provided funding for three weeks training for the VHWs, UNICEF and other
NGOs provided funding for additional training in the two districts visited. The two week
training for CHBCs was adequately funded by the GF. In certain wards visited, some VHWs
were trained for only 3 weeks, with the entire 8-week curriculum crammed into these three
weeks leaving doubts about the uptake and retention of the knowledge passed on in such a
way.
Inadequate supplies and commodities
The health facility staff and community members reported that for a long time the VHWs have
been operating without adequate supplies largely due to the broader supply chain constraints
which have led to the local health facilities operating with inadequate and irregular supplies.
The situation of the CHBCs was somewhat different as they largely depended on the NGOs
and CBOs for their supplies which usually came in the form of HBC kits. Challenges were
however also experienced, as at times they would also require regular replenishments either
from the organisations or the local facilities.
Inadequate support and supervision
The success of CHW programmes hinges on regular and reliable support and supervision. The
interaction of the VHWs and their supervisors was only limited to monthly meetings which
was not adequate to mentor the VHW in performance improvement. It was however later
realised that the VHW cadres would not be adequately supervised without involvement and
guidance from other departments. Currently other specialised departments, including the
Departments of Community Medicine and Epidemiology respectively are now involved in the
training of the cadres.
The supervision of CHBCs provided mainly by the NGOs and CBOs in addition to their
monthly meetings with the health professionals. The approach, though realistic in addressing
coverage, does not offer adequate mentorship support to each of the trained CHBCs. The
monthly meetings with the health professionals are largely feedback oriented in which the
CHBCs share and discuss their report with the health professionals with minimal skills based
supportive supervision.
Numerical inadequacy
The effectiveness of VHWs is adversely affected by a number of factors including: the
inadequate number of personnel engaged to cover the needs of their communities; the lack of
medical supplies and tools to use; and inadequate backstopping support and supervision. Only
one of the 12 facilities visited in the field had the ideal ration of one VHW per village with the
rest serving 3 or more villages with an average of 100 households.
29
CHAPTER 5: FINDINGS - PROGRAM RESULTS
5.1
5.1.1
Perception of community members and leaders on CHW programme
Strengths and weaknesses
While most of the people encountered during the evaluation study perceived the programme
as making a positive contribution to change in the community, the strengths and weaknesses
of the implementation process were noted as well (see Table 4). The utilisation of the services
provided by the CHW by the community is negatively affected by lack or unreliable supply of
medication. In some cases, members of the local community are reported to have lost
confidence in the CHW after several failed attempts to seek assistance due to unavailability of
the required medication forcing the CHW to refer the clients to the nearest health centre. This
was noted particularly in the case clients seeking malaria prophylaxis/ treatment, treatment
for headaches and minor injuries which in the past were readily available in the VHW’s tool
kit. In other instances, CHBCs were reported to be carrying stocks of materials that are no
longer relevant for their clientele such as linen servers.
Table 4: The programme strengths and weaknesses
Strengths
 CHWs providing health education and information
to prevent diseases and awareness of available
health services
 Treatment and support at community level
without having to travel long distances
 Fees and other facility related costs are avoided
 Services provided by those we trust
 Emergencies can easily be attended to within the
community
 Facilitating behavior change in hygiene, HIV
prevention and health seeking behaviors
Weaknesses
 Coverage of activities is low due to
numerical inadequacy of VHWs and their
lack of transport
 Lack of medication and other medical
supplies (bandages) to effectively provide
treatment, care and support in the
community.
 Inadequate and inconsistent provision of
incentives to the CHW.
5.1.2 Perceptions
Perceptions from the following are missing:




RHC staff
Nurse in charge
DMO and DNO
EHT
Indicate what was said on what has changed due to presence of CHWs
5.2
Results of community interventions
5.2.1 Malaria
Figures 2 and 3 show that the trend in the reporting of suspected malaria cases to the health
facilities changed substantial after the CHWs received appropriate training in early 2010. The
training was completed in June 2010 and immediately following that period the number of
confirmed malaria cases reported rose sharply. Although this also seemed to follow the trend
30
in the rainfall patterns in the country a comparison with the figures shows that many suspected
malaria cases are flocking to the health facilities.
100000
Clinical malaria cases, cases tested and cases found positive 2010-2011
90000
80000
70000
C
60000
a
s 50000
e 40000
s
Clinical Cases
Cases Tested
Tested Positive
30000
20000
10000
0
March
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
Figure 2: National Malaria cases and testing trends 2010-2011
120000
Clinical malaria cases, cases tested, cases found positive 2011-2012
100000
C 80000
a
s 60000
e
s 40000
Clinical Cases
Cases Tested
Tested Positive
20000
0
March
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
Figure 3: National Malaria cases and testing trends 2011-2012
5.2.2 HIV/AIDS
The National HIV/AIDS programme continued its efforts to reduce the morbidity and
mortality associated with HIV/AIDs through ensuring a well-coordinated scale up on
interventions namely HCT, PMTCT, OI/ART, Home Based Care and PLWHA as part of a
holistic continuum of care provided through partnership with development partners across
the country. The figure below shows marked improvements in number of people accessing
these services over the years, the role of the CHWs in mobilising became conspicuous in 2010
31
as evidenced by the bigger leap in performance in year 2010 when the CHWs completed
training and begun actively mobilising communities to seek the services as shown in Figure 4.
768341
383792
378930
361355
266043
480185
376500
215879
124924
410045
357183
204696
669672
540990
175291
500000
202083
1000000
326334
Clients
1500000
1108264
2000000
1653603
2500000
1943694
Clients tested at different sites in 2008 to 2011
0
T&C
PMTCT
2008
OI/ART
NGO
2009
2010
Total
2011
Figure 4: Trends in routine HIV/AIDS services 2008 to 2011
In the last two years Zimbabwe has also carried out HTC campaigns that involved intensive
community mobilizations using the CHWs with very good results as can be seen in Figure 5.
In all campaign districts the actual coverage with HTC was well above the set targets due to
the mobilization efforts of well-motivated CHWs.
100%
6044
90%
80%
41968
19105
16819
70%
60%
50%
63956
40%
30%
118032
30895
23181
20%
10%
0%
Mash East
Manicaland
Harare
Achieved
Total
Not achieved
Figure 5: Planned and actual achievements from the 2011 HTC campaigns in
three Districts in Zimbabwe
5.2.3 TB
32
5.3
Cost effectiveness of Global Fund support
The CSS implementation was not cost effective because the total amount spent was more than
the amount budgeted for under the HSS grant as presented in Table 5. Table 5 presents a total
budget for all activities of $4,210,136 and an actual cost of $4,335,484.22 realizing an over
expenditure of $125,348.22 (3% of budget). Cost effectiveness was compromised by a
reprogramming error. The error was such that 5,800 CHWs were targeted for allowances
instead of 7,540. This led to a budget shortfall of $313,200. This shortfall was then provided
for in Q9 leading to the over expenditure. The positive variance realized under training was
due to the non-use of the Year 2 training budget.
Table 5: Budget, Expenditure and Variance of the CSS programme
Activity
Budget
Expenditure
Variance
Training
$1,444,576
$1,336,773
$107,803
Allowances
$2,427,760
$2,660,911.22.
-$233,151.22
$337,800
$337,800
0
$4,210,136
$4,335,484.22
$125,348.22
Uniforms
Total
Source; Round 8, Phase 1 HSS grant documents
Efficiency gains/losses of implementation
As mentioned above, efficiency gains were realized in training activities of CHWs where 354
more CHWs were trained for the same budget. This resulted in the cost of training each CHW
reducing from$ 152.38 as planned to $135.90 over the three week training period. This was
due to lower unit costs realized through the use of cheaper training venues and use of
communal catering services. During implementation the trainers negotiated for lower rates
and also used school venues which charged lower rates. Efficiency gains were also realized in
the procurement of HBC kits under the HIV grant which were wholly funded by other partners.
Efficiency losses were incurred through double funding of training. The Global Fund provided
funding for CHWs training through the HSS grant as well as the malaria and TB grants. In
total $631,808.89 was spent in training CHWs in malaria prevention (2,863) and TB case
management (928). These subjects were also included in the mainstream CHW training
curriculum used under the HSS grant.
Cost ratio analysis
The cost analysis was performed by comparing the estimated ideal and actual cost of
maintaining one CHW per annum. The ideal costs are the estimated cost of providing the
minimum package for effective service delivery by a CHW. The actual costs are the costs
incurred by the Global Fund in maintaining each one of the 11,160 CHWs in Phase 1 of Round
8. The evaluation has shown that a CHW would on an annual basis require a minimum of eight
weeks of initial training, annual refresher training, two uniforms, bicycle and maintenance
costs, allowances, basic kit and administrative fees. Table 6 shows the comparison between
the estimated ideal and actual of maintaining one CHW per annum.
33
Table 6: Cost ratio analysis
Cost Category
Direct cost
Training
Uniforms
Allowances
Bicycle
Bicycle maintenance
Kits and replenishment
Average Cost (US$)
Actual Cost (US$)
449
15
180
90
5
80
168
15
180
0
5
0
814
368
21
21
Total costs
835
389
Ratios
Direct: Indirect costs
39:1
18:1
Sub Total
Indirect costs
Administration costs
Average: Actual package
2:1
Notes:
1. Global Fund supported three weeks of training whilst according to the MoHCW
complete training would take more than 20 weeks. We have however used a minimum
of eight weeks training to compute the estimates.
2. The GF did not fund bicycles and CHBC kits during Phase 1 of Round 8.
The direct to indirect cost ratio (18:1) shows that for every $18 provided by GF, $1 was used to
fund administration cost. The estimated average direct to indirect cost ratio was 39:1. The
comparison between ideal cost versus actual cost ratio shows that GF provided about 46% of
the required funding to maintain one CHW. The direct to indirect cost ratio show that for every
$18 funded by GF, $1, which represents 5.6% was provided to fund administration costs
against an average cost of 2.6%. This means that the GF programme incurred higher
administration costs as a result of the limited budget. The reason for the variance was that
training at inception was reduced from eight to three weeks and HBC kits were provided by
other development partners.
34
CHAPTER 6: SUMMARY FINDINGS
Program design and quality
There is strong evidence that the programme was relevant and appropriate in supporting the
Primary health care approach anchored on community involvement and participation in
improving awareness, access and utilization of health services. At all levels of the systems,
there was appreciation of the importance and necessity of the work of CHWs in supporting the
health system, given the general agreement that the CHWs were contributing positively
towards achievement of planned health outcomes. Generally, the current design of the CHW
component can be sustained as evidenced by overall commitment through adoption and
incorporation of community based approaches into the strategic plans.
Efficiency
The programme was cost effective in as far as more CHWs were trained than planned, in
reducing the distance the community travelled to seek treatment and this seemed cheaper in
terms of transport cost, time costs and also opportunity costs. It was also highlighted that there
was a reduction in the number of home deliveries and increase in health awareness as a result
of the work that the CHWs in the two districts visited during the study. The programme
demonstrated efficiency during training of CHWs as more CHW were trained than planned.
Effectiveness
The programme was effective in ensuring that there was a trained community cadre who was
to be supported to provide both preventive and curative health services. The CHWs were
reported to be enthusiastic and actively involved in providing health services in their
communities with the VHWs covering many more disease components than the CHBC who
were mainly inclined towards providing HIV/AIDS services. However the effectiveness of the
CHWs was affected by their numerical inadequacy, and inadequate support in terms of
supplies, incentives, support, supervision and mentoring. Another aspect noted to affect the
overall effectiveness of this programme and indeed limited organizational learning efforts was
the lack of integration of the VHW reporting (except for some aspects of the TB programme)
into the HIS resulting in non-transmission and non-use of VHW performance data at all levels.
Potential impact
Although no direct causal relationships could be drawn between the HIV and Malaria
programme results with the CSS intervention, there are indications that the intervention could
have contributed positively to the overall outcomes of the disease components.
Sustainability
Although currently the Government of Zimbabwe is still facing liquidity challenges as the
economy undergoes the recovery process, there are indications the initiatives supported under
CSS programme will be sustainable. Therefore, in the short and medium terms, donor funding
will be critical in sustaining current efforts in supporting the Health System in general
including the CSS programme. Incentives such as allowances, uniforms and bicycles are
necessary to boost the intrinsic motivation of the CHWs even after GF support.
35
CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS
7.1
Conclusions
7.1.1
Programme design
There is evidence that the programme was relevant and appropriate in supporting the PHC
approach anchored on community involvement and participation in improving awareness,
access and utilization of health services. Generally, the current design of the CHW component
can be sustained as evidenced by close linkages with existing structures within the MoHCW
and the use of familiar technologies. However, in the short to medium the funding of the
initiatives will rely on substantial support from development partners until the national
economy has recovered to allow for the collection of significant revenues through the fiscus.
7.1.2 Programme implementation
7.1.3 Programme results
7.1.4 Potential impact
Impact prospects in the long term are expected to be very good given the significant
contribution to disease prevention at family and community levels. In the short term the
interventions made have had an impact on both the HIV/AIDS and malaria programs by
facilitating mobilisation of community members to participate in awareness campaigns.
7.1.5 Sustainability
Although currently the Government of Zimbabwe is still facing liquidity challenges as the
economy undergoes the recovery process, there are indications the CHW programme will be
sustainable. However, in the short and medium term, support provided by development
partners will be critical in sustaining current efforts in supporting the Health System in
general including the CSS programme. The provision of incentives such as allowances,
uniforms and bicycles will be necessary to boost the motivation of the CHWs even after the
termination of GF support.
7.2
Recommendations
Harmonisation and standardization of training
There is need to have one standardised training manual for the different groups of CHWs and
this should be based on the harmonization of the integrated VHW and CBHC training
modules. There should be a minimum training package for all community health workers,
which should be developed in consultation and active involvement of all the relevant
departments namely Environmental Health, Nursing, Health Promotion, MCH, HMIS to
name but a few.
There need to have a standardized training model that takes cognisance of minimum training
package and has built in mechanisms for on-going supervision, mentorship and refresher
courses. This model should lay out the roles & responsibilities of different players including
the CHW, and specify timelines for conducting mentorship, supervision and refresher
trainings.
An annual mapping exercise should be conducted that provides for the identification of CHWs
by District, contact Health facility, level of training, community of responsibility, and schedule
of incentives to be received and/or received to date. This will provide the basis for determining
the numerical adequacy of CHWs in a given geographical location as well facilitate planning
36
and coordination of training, support supervision and provision of incentives. It is envisaged
that harmonization and standardization of the training for of the VHW and CBHC training
packages would contribute to improvements in numerical adequacy of the CHWs. It is also
hoped that this mapping exercise would also identify who is doing what, where in terms of
partner support for CSS so that further efforts can be directed to ensure equity.
Incentive package
There is need for a standardised incentive package across the CHWs, and improve
transparency and communication around the incentives vis-à-vis commensurate facilitation
for CHW workload.
Procurement and supply management of pharmaceutical and medical products
There is need to strengthen the overall supply chain systems to ensure reliable and adequate
pharmaceuticals and supplies for health facilities and taking into account the needs of the
CHWs in the area.
Supervision, support and mentorship
The current support for support and supervision should first and foremost emphasise
frequency of support visits from the focal health facility to the CHWs in their workplaces.
Deliberate efforts toward balancing the interactions of both the nurse and the EHT in
supervising the CHWs will go a long way in improving the technical capacity, scope of both
preventive and curative interventions as well as the quality of services provided by the CHW.
There is need for supervision checklists and means of documentation to ensure follow up and
continuous quality improvement.
Monitoring and Evaluation
The CHWs should be regularly and more reliably provided with registers and simplified
summary reporting forms. The HMIS and DHIS should be revised to provide sections for CHW
reporting. A comprehensive M&E framework and system that includes a set of indicators on
provision of necessary inputs, CHW service coverage, and means of measuring performance
the CSS programme should also be developed.
Coordination
There is need for a shared understanding of the results the CSS programme seeks to achieve
in order to improve health service delivery in the country (strategies, goals and objectives), as
well as promote clarity and commonality of purpose among the key user departments of the
CHW cadre.
Given the cross-departmental and integrated management nature of the CSS programme,
there is need to separate the strategic and operational functions of the CSS programme
management through establishment of a ‘home’ to coordinate the routine operational and
administrative affairs of the CSS programme. Whatever department/office is chosen to
coordinate the CHW programme, it must demonstrate ability to satisfy the criteria of being (a)
open and accessible by all the relevant MoHCW departments/divisions/programmes, (b) seek
to be accountable to all stakeholders in CSS, (c) have and implement a jointly developed, timebound and costed work-plan using a known results framework that can be easily monitored
by all, (d) fostering organizational learning through submission of regular reports for review
by all stakeholders, (e) striving to empower and enable functionality of the decentralised
structures of service delivery to coordinate CHW efforts at all levels, (f) be headed by a
dedicated fulltime coordinator who is accountable to all stakeholders, reports to a team of
37
directors/deputy directors drawn from the nursing, environmental health, health promotion,
any other MoHCW sections and major development partners deemed necessary to provide
guidance to the further development of the VHW strategies, and (g) be an active member of
the CCM HSS sub-committee.
These efforts should be emulated at provincial and district levels through quarterly
performance review meetings involving all stakeholders, including review of reports on the
activities and outputs of the CHWs in the communities on, and effectiveness of support,
supervision and coordination of CSS work, amongst other issues at focal health facility level.
Sustainability and options for continued funding
The Government is encouraged to continue increasing its allocations and disbursements to the
programme from the current 6.7 % towards 100% of total need in the long term. We further
recommend that incentives such as allowances, uniforms and bicycles be considered a
necessary component of the CSS programmes at all times.
The Global Fund is encouraged to provide funding for the component through one grant, the
HSS grant. At the moment funding for the component is provided through all the four grants
(as shown in Annex 7, Financial Gap Analysis). All training for CHWs should be coordinated
centrally.
38
ANNEXES
Annex 1: Terms of Reference for the Zimbabwe CSS Evaluation
Brief Background: The Village Health Worker programme in Zimbabwe dates back to
1981, when it was introduced as part of the comprehensive primary health care approach. In
1984, the ownership was transferred to Ministry of Women Affairs, and the VHWs were
renamed as Village Community Workers., with the focus on development and income
generating activities. The VHW programme was reintroduced in 2000, under the Ministry of
Health (Nursing Directorate), to revitalize and focus on health issues and serve as the centre
of community health services. The National Strategic Plan 2009-2013, focuses on established
and retaining trained cadre of Community Health Workers for provision of preventive,
promotive and curative services.
Global Fund and Community Health worker Programme: A decade of high
inflation, severe economic decline and rising poverty led to the departure of skilled health
staff and the deterioration of infrastructure, which have seriously compromised efforts by
the government of Zimbabwe and its international partners to provide universal access to
basic health services and combat HIV, tuberculosis (TB) and malaria. The goal of the Round
8 Cross-cutting HSS programme is to achieve a strengthened and more effective health
delivery system through retention of health workforce, strengthening community health
systems and the scale-up in community programs for the three pandemics.
The Community Health Systems strengthening component included allowances, and
purchasing bicycles, uniforms and other necessary working material an average of 5
community health workers per ward in rural and urban districts. It was estimated that were
on an average of 180 community health volunteers per district, and funding would be based
on this number which is also seen as the minimal number required which can ensure an
effective impact. The country targets are to have 1 VHW per 100 households. A total 6,332
VHWs had been trained by February 2006, leaving a national gap of about 20,000 for this
cadre. The intervention would support over 11000 CHW including the VHW, and bringing in
other CHW groups trained by various partners as CBD and CHBC. The supervision of CHWs
was planned to be strengthened through support to the district health staff that will benefit
from health worker retention program also supported under the current grant. The CHWs
were also to benefit from training and enhanced supervision in specific skill and disease
areas proposed in the three disease component bids, as well as by current and future support
from other partners.
The duties of a VHW include treating minor ailments, providing medical and psychosocial
support to chronically ill patients at home, following up patients, identifying problems in the
community and advising the rural health centres accordingly. They are supposed to work for
2-3 days per week. However, due to the increasing burden from HIV and AIDS and TB, the
job of the VHWs has now become almost full time. Apart from increased work load, these
critical cadres are also faced with a number of other challenges, including (i) inadequate
allowances – at the moment they get less than 1 USD per month; (ii) Lack of transport and
therefore inability to visit all people in need within their catchment areas; (iv) Lack of
uniforms and resource materials, including stationary for record keeping and (v) Limited of
supportive supervision.
The Round 8 grant, had a total proposed budget for USD 9.3 million over 5 years (USD 4
million in Phase 1). During the Phase 2 assessment, the Phase 2 Panel recommended that the
Principal Recipient shall submit a report, in form and substance satisfactory to the Global
Fund on the current CHW work stream in order to (i) measure the return on investment
(cost-effectiveness analysis), and (ii) to identify opportunities for increasing efficiency which
would allow for supporting the CHW work stream with less expenditure.
39
Key Objectives:
Assess if investments in CHW programs, has improved the effectiveness, efficiency and
results of the HIV/AIDS, TB and malaria programs in Zimbabwe.
Provide a comprehensive analysis of potential options for the improving efficiency and
effectiveness of CHW programme, with clear recommendations for preferred options for
continued funding.
Key Evaluation Questions:
Program Design:
Is there any evidence that programs (HIV, TB, malaria and maternal and child health) have
incorporated community based approaches through CHWs into their program strategies?
Is there evidence to suggest that CHWs have participated in and contributed to the three
disease control program, and MNCH?
Is there evidence to suggest that the CHW component as currently designed can be sustained
beyond the Global Fund investments?
Program Implementation:
Have the community health approach interventions been implemented as intended?
Adherence to work plan: service package, delivery approaches and adherence to national
guidelines/procedures, target populations and subgroups
Is there adequate capacity (trainings, and appropriate skill-mix) to implement the planned
interventions?
Is there sufficient coordination and communication between various organizations
implementing community strengthening programs?
What are the facilitating and inhibiting factors in the field implementation of the CHW
program?
Are the health worker skills adequate to meet the increasing scale and scope of the
community respond for the 3 diseases?
Program Results:
Have the CHW program contributed to scaling-up the program strategies/ interventions?
What have been the results of the community interventions on HIV, TB and malaria
diagnosis and treatment, referral and follow-up, linkage between home/community-based
care with facility care and provision of care and support?
What are the enabling and limiting factors for achievement of results?
Is the CHW program supported through Global Fund grant cost-effective? What is the ratio
of direct to indirect costs for maintaining each CHW; what is the cost ratio for delivering
package of desired services as envisaged and actual based on results;
40
Methodology:
Mixed methods approach. Review available secondary CHW program and grant data – on
investments, outputs and results. Key informant interview, to understand challenges and
opportunities for maintaining and scaling up the program.
41
Annex 2: References
1.
The Zimbabwe National Health Strategy (2009-2013); Ministry of Health and Child
Welfare
2.
National Community Home Based Care guidelines; Ministry of Health and Child
Welfare, 2009
3.
The Zimbabwe National HIV/AIDS Strategic plan 2006-2010; National AIDS Council,
2006
4.
The National Tuberculosis Strategic Plan 2010-2014; Ministry of Health and Child
Welfare, 2010
5.
The National Malaria Control Strategy 2008-2013; Ministry of Health and Child
Welfare, 2008
6.
The state of the evidence on programmes, activities, costs and impact on health
outcomes of using community health workers, January 2007, Utah Lehmann and
David Sanders, School of Public Health, University of the Western Cape.
7.
The draft National Village Health Worker Strategy
8.
The Round 8 HIV, TB, Malaria Q1-Q8 PUDRs
9.
A situational Analysis on the status of Women’s and Children’s Rights in Zimbabwe
2005-2010; A call for reducing disparities and improving equity, UNICEF, GOZ,
10.
The Zimbabwe Health Sector Investment case 2010-2012, MoHCW
11.
The Health Transition Fund for Zimbabwe, December 2011, MoHCW
12.
Health Transition Fund for Zimbabwe, Year 1 Implementation Plan, MoHCW
13.
The Village Health Worker Training Manual 2011, MoHCW
42
Annex 3: Criteria for selection of VHWs
1
Maturity age (25 years and older)
2
A mature married residence of the village (woman or man are preferred for stability in
the village)
3
Able to read and write
4
Good reputation in the village
5
A good communicator and mobilise
6
A well respected person in the community
7
Interested in health and development issues (a role model)
8
Willingness to work in the community and on voluntary basis
9
Someone who is able to maintain confidentiality
NB:
i) Single females are less favoured as they will sooner leave the village upon marriage
to the husband’s home
ii) VHWs are recruited to replace those who become inactive or are older and unable
to continue with VHW activities
43
Annex 4: Training curriculum for VHWs
No
Topic
CHAPTER 1: GENERAL CONCEPTS
1.1
Primary Health Care
1.2
Community as a Client
1.3
Communication
1.4
Communication Strategies for Effective Health Education and Promotion
1.5
Health Promotion
1.6
The relationship between Village Health Workers and other Community
Based Practitioners
1.7
Team Approach
1.8
Advocacy, Social Mobilization and Programme Communication
1.9
First Aid
1.10 Non Communicable Diseases
1.11
Mental Health and Mental Illness
1.12
Oral Health
1.13
Psychosocial Support
1.14
Community Home Based Care
1.15
Disability and Community Based Rehabilitation
1.16
Palliative Care
1.17
Nutrition
1.18
Community Based Counseling
1.19
Eye Conditions
1.20 Skin Conditions
1.21
Stigma And Discrimination
1.22 Hazardous Substances
1.23 Planning
1.24 Monitoring and Evaluation
1.25 Preparation, Conducting and Chairing A Meeting
1.26 Report Writing
1.27 Record Keeping
1.28 Support and Supervision of the Community as a Client by the Village
Health Worker
1.29 Stock Management, Supplies And The VHW Kit
CHAPTER 2: COMMUNICABLE DISEASES
2.1
Diarrheal Diseases
2.1.1 Dysentery
2.1.2 Typhoid Fever
2.1.3 Cholera
2.2
Malaria
2.3
Tuberculosis
2.4
HIV/AIDS
2.5
Sexually Transmitted Infections
2.6
Zoonotic Diseases
2.6.1 Anthrax
2.6.2 Rabies
2.7
Bilharzia
2.8
Environmental Health
2.8.1 Water Supplies
2.8.2 Sanitation
2.9
Hygiene
44
Page
5
5
8
18
19
21
22
25
41
48
53
58
60
64
69
72
73
78
81
84
86
90
91
95
97
97
98
100
102
103
104
105
110
113
117
124
127
127
129
133
136
136
140
144
2.9.1
2.9.2
2.9.3
2.9.4
2.10
2.11
2.12
Personal Hygiene
Home Hygiene
Environmental Hygiene
Food Hygiene
Community Based Disease Surveillance
Infection Control at Home and Village Level
Discharge Planning Guidelines
144
150
151
152
154
157
159
CHAPTER 3: MATERNAL, NEONATAL AND CHILD HEALTH
3.1
Antenatal Care (ANC)
3.2
Maternal Morbidity and Mortality
3.3
Neonatal Morbidity and Mortality
3.4
Malaria in Pregnancy
3.5
Labour and Delivery
3.6
Postnatal Care
3.7
Infant Feeding
3.8
Integrated Management of Childhood illnesses
3.9
Diseases Preventable by Immunization
3.10 Nutrition
3.11
Weaning
3.12 Growth Monitoring
3.13 A Child with Diarrhea
3.14 Child Abuse
3.15 Reproductive Health
3.16 Men and Reproductive Health
3.17 Adolescent Reproductive Health
3.18 Family Planning
3.19 Gender
3.20 Abortion
3.21 Infertility
3.22 Menopause
3.23 Andropause
3.24 Cancers of the Reproductive Health System
161
164
166
168
169
171
174
177
181
191
200
201
203
205
207
213
215
217
230
235
237
239
241
242
CHAPTER 4:PREVENTION TOMOTHER AND CHILD TRANSMISSION
(PMTCT)
4.1
Prevention of Mother to Child Transmission (PMTCT)
4.2
Infant Feeding recommendations in the context of HIV
4.3
Breast Feeding
References
249
263
266
273
45
Annex 5: Training curriculum for CBHWs
46
47
Annex 6: A Story of Change by the Dumbamwe Clinic CBHC Team
A Story of Change: CHBC Team Dumbamwe Clinic, Nyagumbo Rural Clinic,
Makoni District Supported by FACT Rusape
We were trained at different times, some of us were trained as HBC caregivers 2006, 2007 and
others 2008 and 2009 by different organisations like GOAL, who are no longer operating here
now. We were trained on different things like others were first trained on HIV and AIDS basic
facts and how to do counselling and conduct support groups, others were trained on how to
conduct home visits and do home based care and others were just Behaviour Change
Commutation Facilitators responsible for distributing IEC materials and condoms. Around
2006 - 2007 HIV/ AIDS was a serious problem and many people were bed-ridden and many
people were dying. There were funerals all over that neighbours would bury their relatives on
a kind of timetable so as to be able to attend the others’ funeral. There was a lot of stigma and
discrimination of PLWHA and lack of knowledge and a lot of misconceptions about the
disease. Other people preferred consulting traditional healers and faith healers so they would
not take counselling serious and kept denying their HIV status.
When this programme came through FACT Rusape, we were told they need about 60 people
to be trained, so we were selected by the community based on the criteria that we are
permanent community members, have good public relations, willing to work for the
community and we were energetic, others had some previous experience and some knowledge
on HIV and AIDS and HBC. 30 women and 30 men were trained.
During the training, we were told that our main job was to provide care and support to the
patients directly and also help the primary caregivers with some chores as well as teach them
on how to care for their patient. The training was very helpful for us as we learnt how to do the
work correctly. At first before training, we:
-
Were not conscious about confidentiality, we would just talk about our clients
sometimes and people would avoid us and say the client is sleeping needs a rest just to
avoid us because of fear that we will talk about them.
Did not know about considering clients’ emotional and spiritual well-being, we just
focused on the physical aspects
Were not able to train the primary care givers on how to care and support their patient,
so we would just do the work for them and leave. This caused problems for some of the
patients, as they would not be assisted in our absence etc.
After FACT trained us, we learnt basic etiquette and CHBC:
- How to get into the household and involve the primary care givers in the care of the
patients.
- We were told that were are secondary caregivers and are not to replace the primary
carers as we do not stay there forever.
- We learnt how to check on how the patient is doing,
- Help turn the patient, change their linen, feed them, talk to them, encourage them to
take medication and so on and so on.
- If they agree, we also prayed for the patient and sometimes help fetch water, clean the
house and yard etc.
- We were also responsible for identifying and referring patients to the clinic for TB
Screening and Treatment
- Providing health education information on specific topics such as ART, TB pain
medication, nutrition, hygiene
- Promoting uptake, use of condoms as well as distributing these and other IEC
materials
48
-
Community mobilization to reduce stigma and discrimination of PLWHA, conducting
weekly support groups
Providing supportive counselling to persons requiring such and encouraging them to
utilise available HIV and AIDS services
The training helped us to be effective in doing our work. In terms of knowledge we could say
it increased from 1/10 to about 9/10 and capacity to perform our duties was also increased
from 1/10 to 8/10. As we undertook our duties, we started noticing that most of our patients
were forthcoming and taking up HIV and AIDS services, enrolling on ART and adhering to
treatment. Attendance to support groups also increased and we were able to form clubs like
now we have soccer clubs for our OVC and some who are living with HIV and have held several
competitions where they won soccer kits and boots for the team. Stigma and discrimination of
PLWHA was reduced in the community and now there is no more finger pointing and
whispering that “wakarohwa nezishiri” “Ariparwendo”, “ndi Code 1”, “ibhazi” kana kuti ane
“AIDS”. PLWHIV now remind each other about collection of their monthly drug supplies with
statements like “when are you going to juice up”,. People are now knowledgeable about HIV,
that it is preventable and manageable. They know each other and solicit support from one
another without hiding their HIV status.
All this is a result of the work that we have done especially with the support from training and
refresher courses that we received from FACT. Right now there is not much work anymore as
most clients are mobile and able to do their usual work, there are very few bedridden clients.
In fact in most circumstances where there is a bedridden patient it will be someone who came
from Harare and very sick with AIDS and ready to die. Our roles and responsibilities have now
slightly lessened as we are now mainly o focusing on on-going counselling, adherence
monitoring (TB DOTS and new ART patients, encouraging people to use condoms consistently
and correctly. We were also distributing condoms and doing community mobilisation to
reduce stigma and discrimination, prevention and referrals to clinics for further support.
Apart from the training, we also feel that this programme provided us opportunities to learn
and help ourselves first before we could reach out to the community, information we learnt
was helpful to ourselves, immediate families and other relatives. We got to know first and
applied it. The incentives that were also provided for us were also helpful although they are no
longer coming these days. We were able to buy essentials like soap, Vaseline, so we could
confidently stand in front of people and talk about health and hygiene while looking smart. Tshirts, hats and uniforms also boosted our confidence because people in the community could
identify us by these. Our work also came with challenges of transport and incomplete
uniforms. We did not have shoes and bicycles but were promised they will be provided. Even
though, this did not necessarily deter us from conducting our duties and we are thankful for
the support we received. We would however wish to receive the incentives on time and if they
could be increased to at least $20 or $30 per month.
We can talk about the most significant changes that this programme brought in different ways.
– At community level, Stigma and Discrimination of PLWHA was significantly reduced
as we have already highlighted. This is also shown by the rate at which people are
taking up HIV and AIDS services.
49
Annex 7: Facility Based Examples of Battery Scores Before and After the
Training (CHWs)
Examples of Battery Scores Before and After
Burnsmack Clinic Training
Before
3/10 After
10/10
– Patakadzidziswa ka, bhatiri rakakwira kusvika 10 bars pa level ya Village health worker
nekuti tisati tadzidza taiti Malaria inyongo, tobva tati vanhu ngavatore mishonga yechivanhu
inokonzeresa running tummy. “ After our training our battery levels rose to those of the
VHWs because before the training we even used to relate malaria with heartburn and even
recommended that those who were ill should take herbs that could cause running tummy”
– We used to also encourage malaria patients to “steam” under the blankets and breathe in the
steam from hot water to get rid of the fevers they will be experiencing.
Burnsmack Clinic Capacity
Before
2/10 After
7/10
– Before training we were using general knowledge that everyone in the community had and in
some cases our strategies failed because people would die even our own relatives
– It’s now about 7/10 because we are practicing what we were taught. It’s not 10/10 because
when they trained us they said information changes on daily basis in the health and so we feel
that we may be overtaken by events given that its been sometime since we had a refresher
course.
Msengezi Clinic
Knowledge
Before
2/10 After
8/10
Our knowledge levels increased.
– Before training we used to think TB chirwere chedzinza nekuti chaibata vanhu vose mumhuri
imwe chete. After training takaziva kuti TB inotapurirwana sei, saka kana tisina kudzivirira,
inogona kubata vanhu vose. Takuziva kuti hembe ne magumbezi anoshandiswa nemurwere
we TB anofanira kuwatshwa, mawindo anovurwa uye mushonga akawutora nemazvo TB
inorapika.
– Before the training we used to think that TB is a disease that was family and genetically
linked as we used to see family members being affected. After the training we now knew
that it is communicable and we aware of the hygiene and treatment requirements in the
care and support of TB clients.
Msengezi Clinic
Capacity
Before
3/10 After
5/10
Reasons for low capacity levels:
– We have other personal HH chores and responsibilities to take care of. During the farming
season, we also have to attend to the fields. At the end of the day we are tired and can’t do our
village health work effectively. We also have to raise finances for to support our families
– Workload is too much, we cover large areas on foot and distances drain our energy before we
reach many clients
– We lack resources to assist us undertake our roles and responsibilities, e.g. VHW Kits, Rain
wear during rainy season when there are usually outbreaks of waterborne diseases.
Msengezi Clinic
Knowledge
Before
1/10 After
9/10
Msengezi Clinic
Capacity
Before
1/10 After
8/10
– Our capacity is compromised because we are no longer able to treat malaria at community
level. Ma referrals hashandi nekuti patient unoitaurira kuti enda ku clinic unotestwa malaria
inokuudza kuti
o hayina mari yekuenda
o Inotarisira kuti ndimupe mari ye transport ne $1 rekubhadara clinic
o Vamwe vakanzwa kuti kunitestwa vanofunga zve HIV ende havaendi.
50
Annex 8: Evaluation Framework
Evaluation Questions
PROGRAM DESIGN
1. Is there any evidence that
programs (HIV, TB, malaria
and maternal and child
health) have incorporated
community based
approaches through CHWs
into their program
strategies?
2.
Is there evidence to suggest
that CHWs have
participated in and
contributed to the three
disease control program,
and MNCH?
Types of answers/
Evidence Needed
Methods for data collection
e.g., records, structured observation, Key informant
interviews, mini-survey
Method
Data sources
Sampling or
selection Approach
(If one is needed)
Data Analysis
methods e.g.…

Analytic description of the
technical approaches/
strategies and objectives of
the programs (HIV, TB,
malaria and maternal and
child health); evidence of CSS
involving established
community health workers

Document/ Literature
review

None
Content analysis and
interpretation of
qualitative findings

Analytic descriptions of the
entire national and district
coordination structures (up
to lowest service delivery
level), quality of the
relationship that exists
whether it’s also supportive
and mutually beneficial
Analytic description of
supportive mechanism for the
work of the CHWs, data
recording and reporting
systems as well as
methodologies used in
aggregation and forward
transmission to the centre;
evidence of use of
information generated to
influence management

Document Review of
program documents,
periodic performance
reports, minutes of
performance review
meetings
Focus Group
Discussions with
partners, stakeholders,
and target groups at
district, health facility
and Community level.
Key Informant
interviews (PR,
MOHCW (Directorate
of Nursing), ZAN and
HSS CCM
subcommittee) and
external informants

Sampling of districts
and communities to be
decided upon during
development of
protocol
Sampling of Lower
levels health facilities
and communities will
be done to achieve a
balance between the
districts and between
good and poor
performing health
facilities/communities.
Content analysis
and
Grounded theory
approach for analysis
and interpretation of
qualitative findings
Consultative
meetings, selection,
analysis, feedback
and verification of
‘Significant Change’
stories



51



National
Strategic & grant
documents,
Project theory of
change, M&E
plan,
performance
(activity,
quarterly,
annual, and
other relevant)
reports; work
plans, budgets,
financial
reports; survey
reports
Disease specific
Policy, Strategic
Plan, and
implementation
guidelines
Grant
documents
District annual
performance
reports
Key informants
from technical
side and
stakeholders at
all relevant
levels especially
the community
level
decisions and refine
implementation
3.
Is there evidence to suggest
that the CHW component as
currently designed can be
sustained beyond the Global
Fund investments?






Analytical Description and
critique of Project Theory of
Change including 1. design
and approaches 2. The
decentralized setting of
health service delivery.
3. Role of Ministry/Programs
& recipient districts in this
process and during
implementation
Analytic description of the
changing political and social
environment and the extent
to which
districts/communities can
develop and implement
comprehensive and
integrated wok plans for HIV,
TB, Malaria & other diseases.
The extent to which services
are provided in an integrated
manner in grant supported
districts.
Establish linkages and/ or
main streaming of GF
reporting systems with the
GoZ HMIS
Establish the
readiness/preparedness of
the district coordination
structures to plan for
prevention activities against
the three diseases beyond GF
investments
Establish the extent to which
GF Round 8 HSS grant has
strengthened health facility






(partners, stakeholders
and target groups at
central, district, health
facility, and community
level).
SWOT analysis
Desk review of program
documents and reports
Focus Group
Discussions as in No. 2
above
Key informant
interviews as above
SWOT analysis
Most Significant
Change Technique
involving project
stakeholders
52



Grant
documents as
above
District annual
performance
reports
Key informants
at National,
Province,
District and
Community
Sampling of districts
to be decided upon
during development of
protocol
Sampling of Lower
levels health facilities
and communities will
be done to achieve a
balance between the
districts and between
good and poor
performing health
facilities/communities.
Content analysis
and
Grounded theory
approach for analysis
and interpretation of
qualitative findings
Consultative
meetings, selection,
analysis, feedback
and verification of
‘Significant Change’
stories

PROGRAM IMPLEMENTATION
4. Have the community health

approach interventions
been implemented as
intended?
Adherence to work plan:
service package, delivery
approaches and adherence
to national

guidelines/procedures,
target populations and
subgroups



5.
Is there adequate
capacity/skills among the
CHW cadre (trainings,
appropriate skill-mix,
supportive supervision,
logistical support, e.g.,
communication, transport
and tools of trade) to meet
the increasing scale and
scope of the community
respond for the 3 diseases,
including MNCH?



based and community based
referral/service networks that
benefit the vulnerable groups
Client perspective of the
services offered by GF R8
HSS supported health
facilities and communities
Comparison of the actual
program results against the
targets prescribed in the
Project Theory of
change/M&E
Plan/Performance framework
(annually)
Compare access and
utilization of services - pre
and post Project intervention
Analytic description of the
factors that hindered or
facilitated the achievement of
program results
Describe lessons learnt and
best practices
Suggest relevant
recommendations

Compare the actual program
results against the targets
prescribed in the Project
Theory of change/M&E Plan
(annually)
Compare access and
utilization of services - pre
and post Project intervention
Compare trends in
performance of the CHW –
pre and post implementation;





Desk review of program
documents and reports
Review the baseline
and periodic
performance
information collected
quarterly and annually
against the project
theory of change and
M&E/Performance
Framework
Key informant
interviews as above
SWOT analysis

Desk review of program
documents and reports
Review the baseline
and periodic
performance
information collected
annually against the
project theory of
change and M&E
Framework

53



Strategic and
grant documents
as in No. 1
Above.
District annual
performance
reports
including HMIS
(Plus DQA
where
necessary) for
major indicators
Key informants
from the
Headquarters,
District Field
staff, District
leaders, disease
focal persons,
Health facility
staffs,
Community
Health Workers)
Strategic and
grant documents
as in No. 1
Above.
District annual
performance
reports
including HMIS
(Plus DQA
where
necessary) for
Sampling of districts
to be decided upon
during development of
protocol and data
collection tools and
after budgetary
considerations
Sampling of Lower
levels and health
facilities will be done
to achieve a balance
between the districts
and between good and
poor performing
health facilities and
communities.
Content analysis and
interpretation of
qualitative findings
Analysis of
performance trends
(routine HMIS and
program/grant
targets) in the
sampled districts
Sampling of districts
to be decided upon
during development of
protocol/data
collection tools; and
after budgetary
considerations
Sampling of Lower
levels and health
facilities will be done
to achieve a balance
between the districts
Content analysis and
interpretation of
qualitative findings
Analysis of
performance trends
(routine HMIS and
program/grant
targets) in the
sampled
districts/communities
6.
7.
Is there sufficient
coordination and
communication between
various organizations
implementing community
strengthening programs,
specifically ZAN’s
community cadre and
MOH’s Village health
workers?
What are the facilitating and
inhibiting factors in the field
implementation of the CHW
program (support from
community, assistance from
health facilities etc)?




PROGRAM RESULTS
8. What is the overall
perception of community
members and community
leaders of the strengths and
weaknesses of CHW
program? What has
changed in the community
due to their presence?

available supportive
mechanisms for the CHWs,
and type and frequency of
logistics provided to support
work of the CHWs
Analytic descriptions of all
the district/community
coordination structures
strengthened by the grant
(including involvement of
partners and other
stakeholders at national,
district and community
levels; meetings,
communication, involvement
of communities and
beneficiary populations in
various project
implementation stages)
Analytic description of the
factors that hindered or
facilitated the achievement of
program results
Describe lessons learnt and
best practices
Suggest relevant
recommendations

Analytic description of the
overall perceptions of the key
“supply side” actors in
Community Health Systems
strengthening component,
the strengths and weaknesses
of the CHW program

Key informant
interviews with the
actors stated in the
question

SWOT analysis

Key informant
interviews as above
SWOT analysis
54


major disease
indicators
Key informants
from the above
stated
and between good and
poor performing
health facilities.
(Time and distance to
play role in the final
sample size)
Key informant
from national,
district, sub
national and
community
levels as stated
in the question
Sampling to be agreed
alongside that of the
districts
Content analysis and
interpretation of
qualitative findings
9.
What have been the results
of the community
interventions on HIV, TB
and malaria program
coverage, and access to
services (diagnosis and
treatment, referral and
follow-up services,
including linkages between
home/community-based
care with institutional care
and provision of care and
support services)?
10. Is the CHW program
supported through Global
Fund grant cost-effective?
What is the ratio of direct to
indirect costs for
maintaining each CHW;
what is the cost ratio for
delivering package of
desired services as
envisaged and actual based
on results?







Comparison of the actual
program results against the
targets prescribed in the
Project Theory of
change/M&E Plan (annually)
Compare access and
utilization of services - pre
and post Project intervention
Analytic description of the
factors that hindered or
facilitated the achievement of
program results
Describe lessons learnt and
best practices

Determination of the direct
and indirect costs of the CSS
component
Determination of clients
serviced by the CHW at
national and local level as
selected in the sample.
Determination of the
standard unit of output
(SOU) and other comparative
indices






Desk review of program
documents and reports
Review the baseline
and periodic
performance
information collected
annually against the
project theory of
change and M&E
Framework
Key informant
interviews as in No. 1
above
SWOT analysis

Literature review
Review approved
budgets, mapping CSS
related costs and
collate and analyse
expenditure reports
Comparison with the
cost of alternative
health services models
e.g. Health Facility
visits Vis-a-vis seeking
care from CHWs

55


Grant
documents as in
No. 1 Above.
District annual
performance
reports
including HMIS
(Plus DQA
where
necessary) for
major malaria
indicators
Key informants
from National,
Province,
District, Health
Facility and
community level
Sampling as above
Sampling of Lower
levels and health
facilities will be done
to achieve a balance
between the districts
and between good and
poor performing
health facilities.
(Time and distance to
play role in the final
sample size)
Content analysis and
interpretation of
qualitative findings
Analysis of HMIS and
other relevant
performance trends
in the sampled
districts/communities
Proposal and
Strategic
documents,
Project theory of
change, M&E
plan, activity,
quarterly and
annual reports;
work plans,
budgets,
financial
reports; survey
reports,
formative KAPB
study report,
and protocols)
None
Content analysis and
interpretation of costs
and other
quantitative findings
Analysis of HMIS and
other relevant
performance trends
in the Country and in
the sampled districts
Annex 9: List of people met and summaries of CHWs met in FGDs
Name of District/ Facility/
Organization
Mashonalanad West PHE
Name of person Met /
Interviewed
Dr Nyamayaro
Mr Marufu
Mr Toma
Mr Gonga
Designation
Provincial Medical Director
Provincial Nursing Officer
Acting Provincial Environmental Health Officer
Provincial Health Services Administrator
Chegutu DHE
Mr Mafukidze
Ms Madondo
Mr Mukorera
Ms Chisena
Mr Chinembiri
Mr Manamike
Ms S Rukasha
Ms Mushipe
Environmental Health Technician
District Nursing Officer
District Health Administrator
Accountant
Pharmacy Manager
Health Information System
Community Health Nurse
Matron
Branswick Council Clinic
Ms Gono
Ms Magaya
Mr Mwala
Second Sister in Charge
Nurse in Charge
Nurse Aid
Mr Zhuwawu
Mr Dengu
Mr Chizanga
Nurse in Charge
General Hand
Nurse Aid
Selous Clinic
Ms Gomani
Ms Nyakunyada
R Nyakurukwa
V Usaiwevhu
Nurse in Charge
PCN
SCN
PCN
Mhondoro Rural Hospital
G. Karumbwana
E. Matemera
Acting Sister in Charge
District Village Health Worker Trainer
Chikara Clinic
N. Gora
Ms Nhandara
W. Nyika
C. Mbendera
Sister in Charge
Health Centre Committee Chairlady
Health Centre Committee Treasurer
Health Centre Committee member
Watyoka Clinic
V. Nyamweda
Mr Chabata
Ms Mhlauri
Sister in Charge
Community Leader
Community Leader
Manicaland PHE
Ms Chikukwa
M. Nyamasoka
S. Hlatywayo
Mr Kupara
Provincial Nursing Officer
ZAN Mutare
NAC Manicaland
NAC Manicaland
Makoni DHE
Ms Benza
Mr Ngwaru
DNO
District Health Administrator
Musengezi Rural Health
Centre
56
Masvosa Clinic
E Kutya
Mr Masvosva
Mr Manyumwa
Mr Jackson
Nurse in Charge
Community leader
Community leader
Community leader
Matsika Clinic
Ms Shamu
Mr D Gumunyu
Mr C. Mazivisa
Sister in Charge
Community leader
Community leader
Dumbabwe Council Clinic
Ms Nyamutswa
Mr M Madziva
Nurse in Charge
Community Leader
Morris Nyagumbo
Memorial Clinic
Mr Nyamande
Ms E. Magaba
Community Leader
Ward Aids Committee
UNICEF
Venue: UNICEF Boardroom
Dr Aboubacar Kampo
Chief, Young Child Survival and Development
Dr Assaye Kassie
Health Manager
WHO
Venue: WHO Boardroom
Dr Custodia Madhlhate
WHO Resident Representative
Dr S. Midzi
WHO
MoHCW
Dr Basera
Mr G.T Mangwadu
Mr D. Rodrick
Ms Chasokela
Global Fund Grants Coordinator, MoHCW
Director, Environmental Health Services, MoHCW
Deputy Director, Environmental Health Services,
MoHCW
Director, Nursing responsible for CSS, MoHCW
Ms J. Siveregi
Director, Zimbabwe AIDS Network (ZAN)
Ms D. Manyarara
CHBC Coordinator, ZAN
Ms J. Musengi
Ms C. Marisa
HOSPAZ
M&E Officer, HOSPAZ
Ms C. Chivodze
Mr G. Mandinde
HOSPAZ
Finance Manager, ZAN
PR/ UNDP Feedback members available June 13, 2012; Venue UNDP GF PR Boardroom
Name
I. Fortes
N. Mujuru
P. Mukweza
N. Mukute
S. Musungwa
M. Deda
Organisation
UNDP
UNDP
UNDP
UNDP
UNDP
UNDP
CCM HSS Sub-Committee members available June 13, 2012; Venue MoHCW 4th Floor
Boardroom
Name
Ms T Shoumilina
Dr S Midzi
Mr. A Phiri
Ms. J Mudyara
Mr. E Boadi
Mrs. G R Dete
Ms. C Marisa
Organisation
UNAIDS (Chair)
WHO
ZAN
MOHCW
UNDP
SAT
HOSPAZ
57
Ms. C Chivodze
Ms. J Musengi
Mrs. T Ndori-Mharadze
Mrs. P Chonzi
Mrs. L Majonga
Ms. I Fortes
Ms. C Chasokela
Mr. N Mukute
Ms. T Westerhof
Dr. C T Basera
HOSPAZ
HOSPAZ
USG/PEPFAR
HSB
MOHCW
UNDP
MOHCW
UNDP
PPAAT
MOHCW
Office of the Director Environmental Health; June 14, 2012
Mr. Mamwadu
Director Environmental Health, MoHCW
Mr. Roderick Tyson
Deputy Director Environmental Health MoHCW
Summary of people involved in community interviews in Chegutu District
Name of Clinic
Branswick Rural clinic
Musengezi Clinic
Selous Clinic
Mhondoro Rural Hospital
Chikara Clinic
Watyoka Council Clinic
VHWs
Males
2
1
0
1
2
0
Females
5
2
5
7
4
6
CHBC Givers
Males
0
0
0
0
2
0
Females
0
0
0
0
5
4
#of People in FGD
7
3
5
8
13
10
Total FGDs =7
Summary of people involved in community interviews in Makoni District
Name of Clinic
VHWs
CHBC Givers
# of People in FGD
Males
Females
Males
Females
Masvosva Clinic
0
6
0
8
14
Matsika Clinic
0
1
0
2
3
Katsenga Clinic
0
3
0
1
4
Dumbamwe Council Clinic
0
4
6
12
22
Nyagumbo Clinic
0
2
6
7
15
Makoni Rural Hospital
NB: At Makoni Rural Hospital no FGDs were done with VHWs and CHBC due to logistical issues. However
discussions were done with the local leadership and health workers present. Discussions were done with 6
village heads and one chief’s representative. Interviews were done with two nurses to discuss the progress and
challenges of the CHW programme within the catchment area of the hospital.
58