National Community Health Worker
(NCHW) Strategy in Zambia
Maternal and Newborn Health Conference for Zambia’s Mothers and Babies
Intercontinental Hotel, Lusaka, 1st November 2012
Presenter: Jenny-Meya Nyirenda
National Community Health Specialist, MOH
1
OUTLINE OF THE PRESENTATION
• Part I: National Community Health Assistant (CHA)
Strategy
• Part II: National CHA M&E Framework
• Part III: CHA Curriculum Review
2
VISION OF NCHW STRATEGY
To have adequately trained and motivated
community-based health workforce contributing
towards: improved service delivery, attainment of
the Millennium Development Goals (MDGs),
National Health priorities and reduction of human
resource for health crisis.
3
GOAL OF NCHW STRATEGY
A cost effective, adequately trained and motivated
community-based health workforce that will
contribute to improved management of malaria,
child and maternal health and common
preventable health conditions.
4
OBJECTIVES OF NCHW STRATEGY
1. Increase access to quality basic health services
at community level via coordination, referral
system and communication with health
facilities.
2. To strengthen prevention of common illnesses
via coordinated health education and
promotion services.
5
OBJECTIVES OF NCHW STRATEGY
3. To improve health seeking behaviour via early
identification and treatment of simple infectious
diseases.
4. To maximize HRH serving the community by
shifting basic uncomplicated tasks to CHA
community level and thus free nurses time to
deal with more technical condition.
5. To coordinate and harmonize activities of other
CHWs to ensure provision of quality health care
in line with National Community Health Strategy
6
NATIONAL SITUATION ANALYSIS
 Zambia has a serious human resources shortage in
health sector.
 A key obstacle to reducing disease burden and
achieving MDGs by 2015.
 In 2009, MoH conducted a Situation Analysis to
assess the community health landscape in Zambia
 Roles, scope and challenges of facilities/
organizations that incorporated CHW services
7
SITUATION ANALYSIS FINDINGS
 CHW services needed across all programmes: estimated 23,500 active
CHWs existed in Zambia
 Training programs by various partners: duration 2 – 11 weeks, vertical and
not aligned to diverse community health needs
 Remuneration: Inconsistent incentive structures for CHWs
 Various CHW titles: health promoters, community health advisors, peer
health educators, lay health advocates etc.
 MOH policy: Lacked official policy to guide management of CHWs
 DMO and implementing partners recommendations: standardization of
guidelines on CHW recruitment, education requirements, training,
remuneration and supervision
8
FOUNDATION FOR THE NCHW STRATEGY
 Evidence from Regional Best Practices:
MOH undertook desk review of CHW programs
being implemented in other countries to identify
best practices - Malawi, Uganda and Ethiopia.
MOH team conducted a study visit to Ethiopia.
 Development of Zambia’s CHW strategy:
Current national situation analyzed and lessons
learnt from other countries applied .
Collaborative consensus-driven process with all
key stakeholders.
9
FOUNDATION FOR THE NCHW STRATEGY
In 2010 MOH created the National Community
Health Worker Strategy, in line with its vision and
aim of the HRH Strategic Plan
 i.e. bringing quality, cost effective and affordable health
services as close to the family as possible
Phased implementation process (pilot & 4 phases)
in-built monitoring and evaluation component.
10
INTEGRATION OF NCHW STRATEGY
INTO NATIONAL HEALTH CARE SYSTEM
Level 3 Hospitals
Level 2 Hospitals
Level 1 Hospitals
11
INTEGRATION OF NCHW STRATEGY
INTO THE NATIONAL HEALTH CARE SYSTEM
 MOH has formalized Community Health Workforce,
it is now named: “Community Health Assistant” (CHA)
 CHAs are not intended to replace the existing
network of community health volunteers, but rather
coordinate and enhance their efforts
Health
Community Health Structure
Non-Community
Health
volunteers*
Meet new qualification
Center
CHAs
Coordinate volunteers
Current Community
Health volunteers*
Volunteer CHWs
Don’t meet new qualification
*A Community Health Volunteer is defined as a non-formalized volunteer who has typically received 2 – 5 weeks of training
12
CAREER PROGRESSION FOR COMMUNITY HEALTH ASSISTANTS
Trainees must
have 2 ‘O’ levels.
They can pursue
the required
Grade 12
certificates so
that they can
enroll in training
as nurses, EHTs,
Clinical Officers,
or Doctors.
CHAs
Formal
HCWs
13
RECRUITMENT PROCESS FOR CHA CANDIDATES
Pilot’s Geographic Reach:
7 Provinces, 47 most rural districts
and 161 remote health posts
MoH defined selection criteria for
Health Posts
 Defined as “hard-to-reach”
 Have a nearby Health Centre for
supervision
 Have poor health indicators
 Health posts without a health
worker or manned by an
unqualified staff
Pilot Participation of
Health Posts
# of HP in the country*
# participating in pilot
275
161
Health Posts
*2010 GRZ Health Facility Listing
14
RECRUITMENT PROCESS FOR CHA CANDIDATES
Selection Criteria for candidates:
 Minimum Grade 12 and 2 “O” levels
 18-45 years old
 Endorsed by Neighbourhood Health Committee (NHC)
 Must be living in same area at time of recruitment
 Preferably previously/currently working as community
volunteers and females.
Selection of candidates:
– Selection panel: NHC, Health Center staff & DMO
–40-50 candidates were selected from 7 provinces (Yr 1)
 Outcome: Pilot class of 307 students
15
CHA TRAINING OVERVIEW
 Modular training - theory and practice - a
set of 11 modules
 Training Plan –integrated & skills-based
learning model – theory then practical
 Primary healthcare focus: prevention,
promotion and basic curative services
 Duration: 1 year training
 Training Registered: By MoH & HPCZ
16
CHA TRAINING OVERVIEW
• An assessment of potential training sites was
conducted in 7 Provinces in 2010
• Major finding: no existing GRZ school had the
capacity to train 300+ students
 A national CHA School was built to train 300+
Picture: Exterior and interior view of classrooms in Ndola, Copperbelt Province
17
Family Health Package
Disease Prevention & Control Package
Disease Prevention &
Control
Environmental Health
Maternal & Child Health
Sexual & Reproductive
Health
•ANC visits
•PNC visits (6,6,6)
•Birth plan
•Nutrition during, and after
pregnancy
•PMTCT
•Nutrition and growth
monitoring
•Immunizations
•Hygiene
• Adolescent health
services
• Gender issues
• HIV & AIDS prevention
(VCT)
• Family Planning
methods
• Infection Prevention
•
•
•
•
•
•
•
HIV & AIDS & STIs
Male Circumcision
Malaria (RDTs),
Diarrhea
Epidemics
TB
Acute Respiratory Illness
(ARI)
First Aid
Health Education &
Communication
• Insect and rodent
control
• Home, personal, &
food hygiene
• Excreta disposal
• Solid and liquid
waste disposal
• Water safety
• Minor cuts & infections
• Bandages
• Emergency care (CPR)
Health Education Communication Approaches are cross-cutting
• Schools
▪ NHC / community meetings
• Churches
▪ Various groups & clubs
18
CHA GRADUATION CEREMONY ON 13 JULY 2012
Presenting Certificates to 307 CHA Graduates
19
CHA GRADUATION CEREMONY ON 13 JULY 2012
The First Class of Community Health Assistants Graduate
20
CHA DEPLOYMENT
 Registration: Qualified CHAs licensed
by Health Professions Council of
Zambia
 Allocation: 2 CHAs per Health Post to
serve their communities, a catchment
area of 3,500 people
 Remuneration: a monthly incentive
 Establishment posts: MoH will seek
Cabinet authority for both CHA School
staff and graduates
21
CHA DRUG SUPPLY CHAIN
Supplies ordered from supervising health centre
Training provided within CHA curriculum
Supervisor to verify records and monitor
consumption used at household & post level
Diagnostics: TB sputum specimen containers,
Rapid Diagnostic Test and Rapid HIV test kits
*For full drug list, please see handout
22
DATA MANAGEMENT
 CHAs trained in data management
 Using standard MOH/CHA registers and
reporting formats
 Compile 1 monthly report per HP
 Submit two sets of report
– hard copy to Supervisor
– Electronic copy using a mobile phone via
internet to Districts, Provinces and MoH-HQ
 System is a building block for MoH’s
“community HMIS”
23
CHA SUPERVISION
Professional health worker InCharge at “parent” health center
supervises CHAs on monthly basis
In-Charge was trained and
equipped with:
Supervisor’s manual and
supervisory tools
 resources to facilitate regular
supervisory visits
24
OUTLINE OF THE MEETING
• Part I: National CHA Strategy
• Part II: National CHA M&E Framework
• Part III: CHA Curriculum Review
25
MONITORING AND EVALUATION FRAMEWORK
(EVIDENCE GENERATION PLAN)
Health Outcomes
Evaluation
Value for Investment
Analysis
Process
Evaluation
Leads: Boston University
/ ZCAHRD & MoH, and
CHAI
Leads: CHAI & MoH
Generate data on:
Document the
effect of CHAs
on the health
system:
Assess process,
functionality &
quality of:
1. Training
1. Volume and
type of patient
visits by cadre
2. Recruitment
2. Productivity of
cadres
4. Management
1. Treatment
of
children < 5 for
malaria, diarrhea &
ARI
2. % deliveries with
a skilled birth
attendant
3. Family planning
acceptance rate
4. % neonates
receiving post-natal
checkup within 1
month
3. Total costs of
training &
employing each
cadre
Analyze:
Productivity vs.
cost each cadre
Leads: MoH, CHAI &
Innovations for
Poverty Action (IPA)
3. Deployment
5. Inventory control
6. Supervision
7. Referral system
8. Community
acceptance
Monitoring
Supervision
Leads: MOH, CHAI
and IPA
Leads: In Charge at
“Parent” Health
Centers, ZISSP, &
CHAI
Assess
achievement of
targets:
Assess and
support:
1. # of household
visits per month
2. # and types of
procedures
carried out
3. # of children
< 5 attended
4. # of pregnant
women attended
5. Follow up with
referrals
1. Quality of CHA
services
2. Compliance
with approved
Scope of Work
3. Use of
medications and
supplies
4. Provide
feedback to
improve CHA
performance
26
MONITORING AND EVALUATION FRAMEWORK
(EVIDENCE GENERATION PLAN)
Health Outcomes
Evaluation
Leads: Boston
Lead:
Boston
University
University/ ZCAHRD
/
& MoH, and CHAI
Value for Investment
Analysis
Leads:
Lead: CHAI
CHAI&&MoH
MoH
ZCAHRD & MoH
Process
Evaluation
Leads: WHO
MoH, CHAI
Lead:
& &
Innovations
for
Harvard/IPA &
Poverty Action (IPA)
MoH
Monitoring
Leads: MOH,
Lead:
MOH CHAI,
&
and
IPA
CHAI, and IPA
Supervision
Leads:
Lead: In
In Charge
Chargeatat
“Parent”
Health
“Parent” Health
Centers, ZISSP, &
Centers, ZISSP
CHAI
Key policy question
answered:
Key policy question
answered:
Key policy question
answered:
Key policy question
answered:
Key policy question
answered:
Do CHAs
improve
community
access to health
care?
What is the
most
productively
efficient skill mix
of cadres for the
Zambian health
workforce?
What changes
should be made
to the CHA
Strategy prior to
the national
scale up?
Are CHAs
reaching the
priority
populations as
expected?
Do CHAs offer
high-quality
services in
compliance with
Zambia’s
regulatory
standards?
27
OUTLINE OF THE MEETING
• Part I: National CHA Strategy
• Part II: National CHA M&E Framework
• Part III: CHA Curriculum Review for the
National Scale up
28
PRIMARY HEALTHCARE PACKAGE FOR CHAS
Disease Prevention & Control Package
Disease Prevention &
Control
Environmental Health
• HIV & AIDS & STIs
• Male Circumcision
• Malaria (RDTs),
• Diarrhea
• Epidemics
• TB
• Acute Respiratory
Illness (ARI)
First Aid
Health Education &
Communication
Family Health Package
Maternal & Child Health
Sexual & Reproductive
Health
• Infection Prevention
• Insect and rodent
control
• Home, personal, &
food hygiene
• Excreta disposal
• Solid and liquid
waste disposal
• Water safety
• Minor cuts & infections
• Bandages
• Emergency care (CPR)
•ANC visits
•PNC visits (6,6,6)
•Birth plan
•Nutrition during,
and after pregnancy
•PMTCT
•Nutrition and
growth monitoring
•Immunizations
•Hygiene
• Adolescent
health services
• Gender issues
• HIV & AIDS
prevention
(VCT)
• Family
Planning
methods
Health Education Communication Approaches are cross-cutting
• Schools
▪ NHC / community meetings
• Churches
▪ Various groups & clubs
29
29
CURRICULUM REVIEWCHANGES TO SCOPE OF WORK
Family Health
1.Family Planning: counsel, initiate and refill oral
contraceptives
- Integrate HIV testing and couple counseling
with FP services
-
Injectable contraceptives (Depo-Provera) by CHAs pending
decision by Health Professional Counsel of Zambia (HPCZ).
- Birth spacing counseling, including for HIV
positive couples and pregnant women to be
added to CHA’s competencies
30
CURRICULUM REVIEWCHANGES TO SCOPE OF WORK
2. Provide pregnancy care (ANC) and Life Saving
Skills during delivery at point of care
 Initiate early ANC follow up by referring to
health facilities
– pregnancy test
– hemoglobin (Hb)
– Urine test (using dipstick)
– Refer pregnant mothers with high sugar and
protein level in their urine.
31
CURRICULUM REVIEWCHANGES TO SCOPE OF WORK
3. Train and equip CHAs with skills to:

Conduct emergency delivery procedures (not
as routine service), in addition to referring
mothers to deliver at health facilities.
 Provide misoprostol in emergency situations
32
CURRICULUM REVIEWCHANGES TO SCOPE OF WORK
4. Postpartum care- at household level:
- CHAs to conduct 48- 72 hour post natal follow up of
mothers with their babies
- Refer those with signs of post partum infection or
any abnormality to a health facility.
 Provide WHO’s Essential Newborn Care including:
– routine neonatal care, resuscitation skills,
– thermoregulation, "kangaroo" [skin-to-skin] care,
– breast-feeding, care of the small baby,
– common illnesses
33
CURRICULUM REVIEWCHANGES TO SCOPE OF WORK
5. Male reproductive health issues: Promote Voluntary
Medical Male Circumcision for infant and adult males at
community level and refer to MC providing sites.
6. Nutrition: integrated approach in all modules
-
Promote/demonstrate child feeding practices through
food preparation using locally available foods.
-
Anemia- administer iron supplements for pregnant
women
-
Vitamins – administer to malnourished children.
7. HIV: Provide VCT services for adults, children,
pregnant mothers…integrated with other services
34
PRIMARY HEALTHCARE PACKAGE FOR CHAS
Disease Prevention & Control Package
Disease Prevention &
Control
Environmental Health
• HIV & AIDS & STIs
• Male Circumcision
• Malaria (RDTs),
• Diarrhea
• Epidemics
• TB
• Acute Respiratory
Illness (ARI)
First Aid
Health Education &
Communication
Family Health Package
Maternal & Child Health
Sexual & Reproductive
Health
• Infection Prevention
• Insect and rodent
control
• Home, personal, &
food hygiene
• Excreta disposal
• Solid and liquid
waste disposal
• Water safety
• Minor cuts & infections
• Bandages
• Emergency care (CPR)
•ANC visits
•PNC visits (6,6,6)
•Birth plan
•Nutrition during,
and after pregnancy
•PMTCT
•Nutrition and
growth monitoring
•Immunizations
•Hygiene
• Adolescent
health services
• Gender issues
• HIV & AIDS
prevention
(VCT)
• Family
Planning
methods
Health Education Communication Approaches are cross-cutting
• Schools
▪ NHC / community meetings
• Churches
▪ Various groups & clubs
35
35
CURRICULUM REVIEWRECOMMENDATIONS TO EXPAND SCOPE OF WORK
• Recommendations for inclusion to CHA scope of
work:
• Disease Prevention & Control Package
1. Create awareness on Gender-based violence and
promote its prevention
2. Promote the new vaccines (H-influenza,
Pneumococcal, Rota) and other immunizations for <5
children
3. Provide First Aid for Poisoning
4. Environmental health: Participate in Community Led
Total Sanitation (CTLS) programs and coordinate other
36
CURRICULUM REVIEWRECOMMENDATIONS TO EXPAND SCOPE OF WORK
5. Prevention and control of common chronic illness:
- Conduct rapid blood glucose test and urine test
for sugar to diagnose Diabetes among people
with signs and symptoms and refer to health
facilities.
- Promote health lifestyle and prevention of
chronic illnesses like diabetes and hypertension.
- Provide adherence counseling for patients on
medication for chronic illnesses and refer the
“lost to follow up” clients to health facilities for
re-start.
37
Thank You
Twa
Lumba!
Zikomo!
38