IGC: Africa Growth Forum 2015: Addis Ababa, Ethiopia
(June 29 – July 1)
Dr Joseph N. Kandeh
Director, Primary Health Care, Ministry of Health and Sanitation
joeagie90@gmail.com
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OUTLINE OF THE PRESENTATION
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Background of Sierra Leone
Situation and Impact of Ebola Virus diseases
CHW program in Sierra Leone
Urban CHW approach
CHW interventions in the EVD response
Lesson’s from the EVD
Challenges
Next steps
Conclusion
Acknowledgment
BACKGROUND OF SIERRA LEONE
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Country Population - 6.5m: under five
pop. - 1,150,500; pregnant women pop
- 286,000 (Projection from 2004 census)
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Administrative division - 4 regions
(including Western Area of 69 Local
Council Wards ), 12 districts of 149
chiefdoms
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40 Hospitals (private and public) and
1,185 (Peripheral Health Units) PHUs
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1 Medical school, 11 Nursing schools, 2
Midwifery schools, 2 (Community
Health Officers/Assistants) CHO/CHA
school (one Functional) and 14
Maternal Child Health Aide (MCH Aide)
training schools
BACK GROUND TO CHW
 Community programme has been in existence for
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a long time with little recognition
Traditional Births Attendance (TBAs), Community
Motivators (EPI), Home Management of malaria
(HMM), Community Drug Distributors (CDD for
Neglected Tropical Diseases), Blue Flag Volunteers
(Diarrhoea prevention and control) etc.
Under one umbrella = COMMUNITY HEALTH
WORKERS (Volunteers)
Policy, strategy and training manual developed and
validated b4 Ebola Viral Disease (EVD)
Considering *post Ebola syndrome or effects* in a
resilient healthcare delivery system
EBOLA SITUATION
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Declared EVD outbreak on
23rd, May 2014
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All districts, all age group and
both sexes are affected with
varying degrees
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8,611 confirmed cases and
3,545 confirmed EVD deaths (as
of 27 May 2015)
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Heavy loss of health personnel
(304 cases and 221 deaths)
(25 death/month on average)
Confirmed, probable and suspected
EVD cases
The Epidemic curve
IMPACT OF EBOLA ON HEALTH SYSTEM
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Health worker infections
-25% variance decrease in general utilization rate (distrust of
health personnel, fear of contracting EVD…)
Immunization: reduced by 50%
Percent change in number of visits during Ebola (Oct 2014-Jan 2015) vs pre-Ebola (Oct 2013- Jan 2014)
Highly affected
districts (Port Loko,
Bombali, Western)
Non-highly affected
districts
Nationally
ANC 4
-25%
-9%
-14%
Penta 3
-27%
-11%
-17%
Deliveries
-19%
0%
-7%
U5 children treated for
malaria
-47%
-27%
-31%
Tracer MCH services at
PHU level
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Increase pressure on supply chain for commodities (competing
priorities with EVD + travel restrictions)
Rise in teenage pregnancy
Health Sector Recovery Framework
Key Expected Results
 Safe and healthy work settings
 Adequate Human Resources for Health
 Essential (basic) health and sanitation services are available
 Communities able to trust the health system and access essential health services
 Communities able to effectively communicate and effectively send health alerts
 Improved health system governance processes and standard operating procedures
 International Health Regulations (IHR) followed
Patient & Health Worker Safety
Outputs
Health Workforce
Outputs
Essential Health Services
Outputs
Community Ownership
Outputs
Surveillance &
Information Outputs
Sierra Leone Basic Package for Essential Health Services (BPEHS) – Fully implemented by 2020
Patient & Health Worker Safety
•PS and health services & systems
development
•National PS policy
•Knowledge & learning in PS
•PS awareness raising
•Health care-associated infections
•Health workforce protection
•Health care waste management
•Safe surgical care
•Medication safety
•PS partnerships
•PS Funding
•PS surveillance & research
Health Workforce
•National & 3 regional referral
hubs for quality care
•Establish a medical post-graduate
centre
•Strengthen national & 3 regional
training institutions
•Establish CPD programmes for all
health cadres
•Improving individual, provider and
sector performance
•Strengthening ethics and health
regulations
Essential Health Services
•Integrated Management of Childhood Illness
•Core malaria control interventions, including
HIV/AIDS and TB
•Maternal & Child life-saving interventions
•Teenage Pregnancy prevention
•Non-Communicable Diseases
•Essential Medicines & Supplies including PPEs
•Improve referral including revitalization of the
national ambulance service
•Diagnostic laboratories & blood transfusion
•Rehabilitation & facility equipping
•Health promotion, environmental health &
sanitation
Community Ownership
•Revise policy and
guidelines on Community
leadership
•Community dialogue
•Community-based
approaches
•Linkages between facility
and community
•Improve community initiated
health alerts
Information & Surveillance
•Disease surveillance &
database
•District health information
system (DHIS2)
•Human Resource
information system (HRIS)
•Logistics Management
Information System (LMIS)
•Burden of disease studies
•National Health Accounts
Enabling Environment: Leadership & Governance, Efficient Health Care Financing Mechanism and Cross-Sectoral Synergies.
CHW PROGRAM IN SIERRA LEONE
 iCCM in 6 districts
 RMNH in other districts
 Technical leadership; MoHS
2014
2013
2012;
- National
CHWs policy
launched
2010; iCCM - iCCM scaled
– 2 districts up in to more
districts
- Linked with
the PHUs
- evolved to
include
promotion of
MNH
services
- Scaled up
in 6 more
districts (2
iCCM and
MNH; 4 only
MNH)
- One more
district
started
implementi
ng the MNH
and UNICEF
 UNICEF funding Implementing
NGO partners is the main
modality of Implementation
CHW PROGRAM IN SIERRA LEONE
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Coordination: National CHW Hub office (Program in the directorate
of Primary Health Care), National CHWs taskforce and TWGs
District Focal, Chiefdom in-charges, PHU supervisors etc.
All CHWs are volunteers with non financial and small financial
incentives (variable)
Services provided include:
 Integrated Community care of malaria (iCCM)
 Home visits for (Reproductive, Maternal and New Born Health)
RMNH service promotion (facility visits for Ante Natal Care (ANC),
delivery, Post Natal care (PNC), identify and refer of danger signs
during pregnancy)
 Promotion of key healthy behaviors (use of Long Lasting Insecticide
Treated Mosquito nets (LLITNs), hand washing, use of toilets, family
planning)
CHW INTERVENTION IN THE EVD
Social mobilization
BCC focus on;
- Hand washing,
- Early care seeking
- Isolate suspected cases
- ABC (Avoid Body Contact)
Burial team
Members of the
dignified and safe
burial teams
Contact Tracers
- Trained as contact tracers
- Identify contacts of
suspected and confirmed
cases/deaths
- Report and monitor
identified contacts
- 96,507 EVD alerts by
CHWs (Dec 2014 to May
2015)
CHW INTERVENTION IN THE EVD
 Continue delivery of iCCM/RMNH
program
 9,715 CHWs trained on the “no
touch policy” guideline for service
delivery during the EVD period:
- assessment based on observation
and no touch of a sick child or
mother
- Presumptive treatment of Fever
- MUAC measurement done by
mothers and reading by CHWs.
Community Event Based surveillance;
(7,011 trained: 70%);
Identify 6 triggers in the community and
report to DERC;
 2 or more family members sick/die
in short period,
 Any one sick/die after an unsafe
burial/handling corpse
 Traditional healer/Health Worker
sick/die of an unknown cause
 Any traveler/returnee from other
village become sick/die
 Anyone with a contact with EVD
became sick/die
 Unsafe burial practices in a
community
LESSONS FROM THE EVD
During EVD
Before EVD
• Link communities to • CHWs acknowledged as core
to primary health care
PHUs
delivery system.
• Facilitate increase in
facility utilization
• Treating as many
children as PHUs
• Reduction in child
mortality
 CHWs are playing a
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marvelous role in bridging
the gap between
communities and PHUs;
leading to increase in service
intake
Establishment of the
community ownership pillar
(CHW); one of the five key
pillars of the recovery plan
CHALLENGES
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Close to 70% of the CHWs are Male; difficult to provide
RMNH services (Low literacy rate especially for females)
No incentive scheme (only transport reimbursement for
CHWs - $3 per month to monthly meeting)
During Ebola, CHWs paid higher rates (average of $80 per
month) which can’t be afforded by the national health
system
Poor supply chain management (at Central, PHUs and CHWs
level)
Funding; especially to establish an attractive incentive
scheme to the CHWs, medicines procurement and national
scale up of the program.
Acceptance/recognition of CHWs as complementary Health
workforce ; including Traditional Health workforce and no
rivalry
More demand/high expectations with little or no benefit
NEXT STEPS
 Total review of all CHW policies and strategy to
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include Integrated Disease Surveillance and
Response (IDSR) and other EVD learnings
Establishing a national registry of CHWs through a
Geo-mapping exercise (July 2015).
Resource Mobilization
Revitalize the health system, including the
Implementation of the CHWs program in all
districts.
Advocacy/lobbying for CHW programme national
budget line
CONCLUSION
 Resources (especially finance) are scare and limited
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(recognition and judicious use)
Motivation = Retention (BEST Method ???)
Material; Financial (incentives?)
Career pathway (creating job opportunity)
Performance Based Financing (PBF) – Health Facility vs
Community/CHW)
Traditional Health workers recognition/acceptance
(Complimentary Health worker force vs Rivalry)
Our mandate: Provide affordable, accessible and
equitable quality health care services for the people in
Sierra Leone
WHAT THEN IS THE BEST METHOD ?????
THE END
 Thank you for your wonderful attention!!
 What do you advice/suggestions???
ACKNOWLEDGMENT
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Government of Sierra Leone; MoHS, DHMTs
Community health workers
UNICEF
International rescue Committee (IRC)
Save the Children
IGC (International Growth Centre)
World Hope International
Development Initiative Program (DIP)
Partners in Health