PROF SENGA K PEMBA, PHD
TANZANIAN TRAINING CENTRE FOR INTERNATIONAL
HEALTH
TTCIH, IFAKARA 22 JULY 2011
Introduction
 Despite an increase in health spending in Africa,
many people have limited access to good quality
health care, especially in remote and rural areas.
 The burden of diseases such as HIV, TB and
malaria, lack of health workers and management
and organisational failures are all attributed to
weak health systems in these countries
WHO’s view of a health system
 According to the World Health Organization (2000) a
health system is “all activities whose primary purpose is
to promote, restore, and maintain health.”
 However, in recent years, the definition of “purpose”
has been further extended to include the prevention of
household poverty due to illness.
 Thus: “all activities whose primary purpose is to
promote, restore, and maintain health including the
prevention of household poverty due to illness.”
Enabling
sub-system
inputs…
…generate
system
outcomes…
Integrated service
components
Health workforce
size, composition
& training
Information for
decision-making
Essential drug
supply & logistics
Enhanced
access to
services and
technologies
Extended
range of
services and
technologies
Health financing &
resource allocation
Improved
quality of
services
Leadership &
governance
Improved
efficiency
Effective Health System
…that alter the
climate of
demand for
services
…impact on
health
behavior,
and ….
Improved
equity
Enhanced
Health
Service
Utilization
Reduced
social costs
Source : IHI
Improve
survival
The focus of an effective health system
 The key functions of a health system as earlier on
discussed focus on:
 Health service provision,
 Ensuring Human Resources for Health (with the
requisite skills, in correct numbers, skills mix) are
available
 Ensuring Information for planning and decision
making is in place
 Ensuring medical products, vaccines and technologies
are in place
 Stewardship
 Health financing
 Households’ demand and behavior largely determine
how these functions perform.
Key functions of a health system ctd…
 In order to strengthen a health system you
need to ensure that the needs of the poor and
vulnerable communities are adequately
addressed.
 The 1978 Declaration of Alma Ata recognises
the Community as part of a health system
 You can therefore only effectively address
population health needs and burden of
disease if policies can focus on health services
provided at the community level.
We need a Health system that cares
The case of Tanzania
• Tanzania is making progress towards MDGs
but mortality is still too high:
•
MMR: 578 per 100,000 live births
•
U5MR: 112 per 1000 live births
•
NMR: 32 per 1000 live births
• Community and health system linkage is weak
• Coverage of cost-effective interventions is low
•
Current coverage levels not sustainable
Coverage of Selected Cost Effective Interventions
2010
Source Shoo &
Mzige 2010
96
93
84
88
57%
57
64
53
51
41
27
24
0
Key questions on the health system…
• The key questions which require urgent
answers are:
• How to best deliver integrated MNCH
package?
• How to increase demand and utilization?
• How to maximize the impact of these
interventions?
10
Some practical solutions!
 There are however, practical/affordable
health interventions that are available!
 Providing effective health extension to
communities and households
 Supporting the government to strengthen
Community Health work as articulated in
the Primary Health Services Development
Plan of 2007, the RCH Roadmap and the
Human Resource Development Strategy.
 All the above can be achieved through the
use of Community Health Agents
A Quote to start with….
“Essential health services cannot be provided
by people working on a voluntary basis if
the services are to be sustainable. While
volunteers can make a valuable contribution
on a short-term or part-time basis, trained
health workers…should receive adequate
wages and/or other appropriate and
commensurate incentives”.
Task shifting: rational redistribution of tasks among health workforce
teams [Global recommendations and guidelines, recommendation 14].
Geneva: World Health Organization; 2008.
Trained and paid health workers are key
Who is a Community Health Agent (CHA)?
 A CHA is a health worker, selected by the community
where he/she lives, formally trained and works in his/her
own community performing a diverse range of roles and
activities
 CHAs have the capability to reach out to rural
communities/households facing major barriers in
accessing health services
 In carrying out such duties, CHAs are assisted by Enrolled
Nurses, Health Assistants, Clinical Assistants, Clinical
Officers and other social workers
 Over the past one year the Tanzanian Training Centre in
International Health Ifakara has embarked on training
this cadre of CHAs
Locations where CHAS will work
Kilombero and
Ulanga in Morogoro
Rufiji in Coast
Region
15
Evidence base in support of CHA
1. Community and HH based interventions have 61%
2.
3.
4.
5.
impact on mortality
Integration of services is more efficient and cost
effective
Most interventions that reduce mortality and
morbidity can be delivered at community level using
CHAs
CHAs have been found to effectively promote the
uptake of interventions at the community level.
It is much easier and less costly to train a CHA than
other health professionals who take many years of
training but also unwilling to work in rural
communities
How different health workers fit in a health system
Source: WHO 2000
Where do CHAs fit in the health system? ctd…
 The appropriate location for Community health
Agents is at the community level just like what the
pyramid shows
 At this level CHAs bridge the gap between health
facility and the house hold
 They in addition form part of the referral system
 It is on this basis CHAs are considered and
recognized as an integral part of the health
system
CHAS within the TZ health system
 The training of CHAs is part of an intervention study
under the Ifakara Health Institute (Connect project) to
introduce a formally trained and paid multi tasked CHA
linked with a District wide Emergency Referral System
 This intervention will Strengthen the health system by
way of providing a link between the health facilities
and villages/households by providing the right type of
HRH to facilitate accessibility of information, medicines
and supplies, improving organization of work from the
community-level up, including timely emergency
referrals
Design of the CHAs training programme
 The CHAs training curricular is deigned on the principles
of Competence based education
 It is a one academic year (36 Weeks) programme divided
into two levels: National Training Award (NTA) Level 4
and 5.

NTA Level 4 has a total of 18 weeks divided into two
semesters of nine weeks each
 Similarly, NTA Level 5 has also 18 weeks divided into
two semesters of nine weeks each
 There is field work during NTA Level 5 of 4 weeks which
is implemented in the Villages where the trainees came
from.
Design of the CHAs training programme ctd...

Each session has a module specifically developed for
that session. The modules are important in guiding
trainers on what to teach and assess

IMCI and Community IMCI are among the sessions
covered during the course. IMCI is an important
component in assisting CHAs to manage childhood
illnesses
 During the training phase, the Supervisors for CHAs
are mainly the trainers though Village leaders have
to oversee the trainees performance in the field
Training of CHAs: what and how was it done?
 Training Needs Assessment (TNA) was successfully
completed using a variety of methods and tools
 An occupational profiling of existing community
health workers was conducted to identify the
appropriate competencies for the new cadre of
CHAs
 Based on the competencies derived, development of
a competence based curriculum was then
undertaken using experienced medical educators.
Training of CHAs: what and how was it done? ctd…
 Development of relevant training modules was also






undertaken using a team of experts
Orientation of trainers for the CHAs was conducted by
experienced Master Trainers
Recruitment of 58 trainees in collaboration with Villages
was successfully done
Delivery of CHAs training programme started in
October 2010
CHAs field work was successfully done in April/May 2011
Training of supervisors (technical and community) was
successfully done
1st batch of CHAs (57) graduated in July 2011 and are now
back to their home villages ready to provide service
Roles of CHAS
1.
2.
3.
4.
5.
Conduct households baseline data collection,
update Village Register, routine household visits
Routine distribution of key household health
“technologies”/commodities that prevent illnesses
Health education, counseling on key aspects of
general health
Mobilize for birth planning, facility delivery, post
partum visits and care for mothers and newborns
Early treatment and follow up of children with
uncomplicated illnesses
Roles of CHAS ctd…
6.
7.
8.
9.
10.
11.
12.
Conduct community diagnosis
Collaborate and network with other sectors
in the community
Provide home-based care
Promote nutrition at the community level
Participate in planning, implementation,
monitoring of village activities
Participate in disease prevention and control
Manage common illnesses
Are there opportunities for scaling up CHAs
training in TZ?
The answer is YES!!
1. Renewed interest globally – WHO, GHWA,
UNICEF, etc
2. Institutional and policy frameworks
supportive – HRH Strategy ,RCH Roadmap,
MMAM
3. Funding opportunities within the fiscal space:District Councils, Cost recovery , CHF etc
4. Widespread use of mobile phones technology
– 62% of HH have access.
Are there challenges ahead?
Many BUT can be solved!!
 Recognition of the new paid community based
health cadre in Health Workers Scheme of Service
in Tanzania
 Payment of the new health cadre
 Sustainable monitoring and support by the health
system to ensure functionality of the cadre:
 Medicines and supplies
 Feedback to community and service delivery data
collected by CHAs
 On the job training
 Maintaining functional linkages with existing
community governance and accountability structures
END
THANK YOU CHAS FOR CARING FOR US!