1. 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

2. OUTLINE OF THE PRESENTATION
Part I: National Community Health Assistant (CHA) Strategy
Part II: National CHA M&E Framework
Part III: CHA Curriculum Review

3. 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.

4. 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.

5. OBJECTIVES OF NCHW STRATEGY
Increase access to quality basic health services at community level via coordination, referral system and communication with health facilities.
To strengthen prevention of common illnesses via coordinated health education and promotion services.

6. OBJECTIVES OF NCHW STRATEGY
To improve health seeking behaviour via early identification and treatment of simple infectious diseases.
To maximize HRH serving the community by shifting basic uncomplicated tasks to CHA community level and thus free nurses time to deal with more technical condition.
To coordinate and harmonize activities of other CHWs to ensure provision of quality health care in line with National Community Health Strategy

7. 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

8. 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

9. Evidence from Regional Best Practices:
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.
Main points:
Vast research done on other countries’ CHA programs and Zambia used best practices from each country’s strategy
Stakeholder involvement has been sought since the beginning of the Strategy being drafted and will continue to play a large role in moving the project forward
Because of the new MoH CHA Strategy and processes put in place, MoH is dedicated to ensuring a rigorous health outcomes study, process evaluation and analysis of value for money

10. Phased implementation process (pilot & 4 phases)
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.
Main points:
Vast research done on other countries’ CHA programs and Zambia used best practices from each country’s strategy
Stakeholder involvement has been sought since the beginning of the Strategy being drafted and will continue to play a large role in moving the project forward
Because of the new MoH CHA Strategy and processes put in place, MoH is dedicated to ensuring a rigorous health outcomes study, process evaluation and analysis of value for money

11. INTEGRATION OF NCHW STRATEGY INTO NATIONAL HEALTH CARE SYSTEM
Level 3 Hospitals
Level 2 Hospitals
Level 1 Hospitals
Main Point: CHAs will be stationed 20% of their time at the health post level- the lowest level of health service delivery- and 80% of their time within the community

12. 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
Volunteer CHWs
CHAs
Meet new qualification
Don’t meet new qualification
Coordinate volunteers
Non-Community Health volunteers*
Current Community Health volunteers*
Health
Center
Community Health Structure
Implementation guide completed to help articulate these issues to the PMOs, DMOs, Supervisors and CHAs. Will be disseminated to all prior to July deployment.
*A Community Health Volunteer is defined as a non-formalized volunteer who has typically received 2 – 5 weeks of training

13. 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
CO, MD
EHTs
Nurses
Pursue additional required education
Graduate from CHA Training Program
Main Point: As a best practice, CHAs will have a clearly outlined career path. From CHA cadre, there is the opportunity to become a Formal Health Care Worker

14. 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
Main point is that best practice was used as candidates were selected by their own communities.
*57% of all the Health Posts are participating
*2010 GRZ Health Facility Listing

15. 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
Main point is that best practice was used as candidates were selected by their own communities
*58% of all HPs are participating

16. 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
Main Points:
1 year training
registered by a regulatory body
Prevention is the CHA’s focus
Main health issues covered: malaria, respiratory illnesses, diarrheal diseases, TB, HIV& AIDS, maternal and child health

17. 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

18. SCOPE OF WORK: PRIMARY HEALTHCARE PACKAGE
Disease Prevention & Control Package
Family Health Package
Disease Prevention & Control
Sexual & Reproductive Health
Environmental Health
Maternal & Child Health
Infection Prevention
Insect and rodent control
Home, personal, & food hygiene
Excreta disposal
Solid and liquid waste disposal
Water safety
HIV & AIDS & STIs
Male Circumcision
Malaria (RDTs),
Diarrhea
Epidemics TB
Acute Respiratory Illness (ARI)
ANC visits
PNC visits (6,6,6)
Birth plan
Nutrition during, and after pregnancy
PMTCT
Nutrition and growth monitoring
Immunizations
Hygiene
Adolescent health services
Gender issues
HIV & AIDS prevention (VCT)
Family Planning methods
Main Point: CHAs will be responding to the vast health needs of their community with special focus on Zambia’s disease burden.
Minor cuts & infections
Bandages
Emergency care (CPR)
First Aid
Health Education & Communication
Health Education Communication Approaches are cross-cutting
Schools ▪ NHC / community meetings
Churches ▪ Various groups & clubs

19. CHA GRADUATION CEREMONY ON 13 JULY 2012
Presenting Certificates to 307 CHA Graduates

20. CHA GRADUATION CEREMONY ON 13 JULY 2012
The First Class of Community Health Assistants Graduate
307 students graduated in July 2012

21. 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
CHAs will be registered, 2 CHAs per health post, CHAs will be compensated monthly for their work, and if proven a good investment MoH will work to put them on the MoH Establishment

22. Supplies ordered from supervising health centre
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
CHAs will be registered, 2 CHAs per health post, CHAs will be compensated monthly for their work, and if proven a good investment MoH will work to put them on the MoH Establishment

23. 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”
CHAs will be registered, 2 CHAs per health post, CHAs will be compensated monthly for their work, and if proven a good investment MoH will work to put them on the MoH Establishment

24. In-Charge was trained and equipped with:
CHA SUPERVISION
Professional health worker In- Charge at “parent” health center supervises CHAs on monthly basis
In-Charge was trained and equipped with:
Supervisor’s manual and supervisory tools
resources to facilitate regular supervisory visits
Health Centres will supervise CHAs and there will be 1 Supervisor: 1 Health Post
The In-charge will supervise and will be trained on how to conduct effective CHA supportive supervision

25. OUTLINE OF THE MEETING Part I: National CHA Strategy
Part II: National CHA M&E Framework
Part III: CHA Curriculum Review

26. MONITORING AND EVALUATION FRAMEWORK
(EVIDENCE GENERATION PLAN)
Health Outcomes Evaluation
Leads: Boston University / ZCAHRD & MoH, and CHAI
Generate data on:
1. Treatment of children < 5 for malaria, diarrhea & ARI
2. % deliveries with a skilled birth attendant
3. Family planning acceptance rate
4. % neonates receiving post-natal checkup within 1 month
Value for Investment Analysis
Leads: CHAI & MoH
Document the effect of CHAs on the health system:
1. Volume and type of patient visits by cadre
2. Productivity of cadres
3. Total costs of training & employing each cadre
Analyze: Productivity vs. cost each cadre
Process Evaluation
Leads: MoH, CHAI & Innovations for Poverty Action (IPA)
Assess process, functionality & quality of: Training
2. Recruitment
3. Deployment
4. Management
5. Inventory control
6. Supervision
7. Referral system
8. Community acceptance
Monitoring
Leads: MOH, CHAI and IPA
Assess achievement of targets:
1. # of household visits per month
2. # and types of procedures carried out
3. # of children < 5 attended
4. # of pregnant women attended
5. Follow up with referrals
Supervision
Leads: In Charge at “Parent” Health Centers, ZISSP, & CHAI
Assess and support:
1. Quality of CHA services
2. Compliance with approved Scope of Work
3. Use of medications and supplies
4. Provide feedback to improve CHA performance
Main Points: M & E framework has 5 components- and each being led by 1-2 partners and the MOH.
Partners: Boston University, Innovations for Poverty Action (IPA), CHAI = Clinton Health Access Initiative
ZCAHRD = ; ZISSP =

27. MONITORING AND EVALUATION FRAMEWORK
(EVIDENCE GENERATION PLAN)
Health Outcomes Evaluation
Lead: Boston University / ZCAHRD & MoH
Value for Investment Analysis
Lead: CHAI & MoH
Process Evaluation
Lead: WHO & Harvard/IPA & MoH
Monitoring
Lead: MOH & CHAI, and IPA
Supervision
Lead: In Charge at “Parent” Health Centers, ZISSP
Leads: Boston University / ZCAHRD & MoH, and CHAI
Leads: CHAI & MoH
Leads: MoH, CHAI & Innovations for Poverty Action (IPA)
Leads: MOH, CHAI, and IPA
Leads: In Charge at “Parent” Health Centers, ZISSP, & CHAI
Key policy question answered:
Do CHAs improve community access to health care?
Key policy question answered:
What is the most productively efficient skill mix of cadres for the Zambian health workforce?
Key policy question answered:
What changes should be made to the CHA Strategy prior to the national scale up?
Key policy question answered:
Are CHAs reaching the priority populations as expected?
Key policy question answered:
Do CHAs offer high-quality services in compliance with Zambia’s regulatory standards?
Main Point: Review the policy question each component answers

28. 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

29. PRIMARY HEALTHCARE PACKAGE FOR CHAS
Disease Prevention & Control Package
Family Health Package
Disease Prevention & Control
Sexual & Reproductive Health
Environmental Health
Maternal & Child Health
Infection Prevention
Insect and rodent control
Home, personal, & food hygiene
Excreta disposal
Solid and liquid waste disposal
Water safety
HIV & AIDS & STIs
Male Circumcision
Malaria (RDTs),
Diarrhea
Epidemics TB
Acute Respiratory Illness (ARI)
ANC visits
PNC visits (6,6,6)
Birth plan
Nutrition during, and after pregnancy
PMTCT
Nutrition and growth monitoring
Immunizations
Hygiene
Adolescent health services
Gender issues
HIV & AIDS prevention (VCT)
Family Planning methods
Minor cuts & infections
Bandages
Emergency care (CPR)
First Aid
Health Education Communication Approaches are cross-cutting
Schools ▪ NHC / community meetings
Churches ▪ Various groups & clubs
Health Education & Communication

30. CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
Family Health
Family Planning: counsel, initiate and refill oral contraceptives
Integrate HIV testing and couple counseling with FP services
Injectable contraceptives (Depo-Provera) by CHAs pending decision by Health Professional Counsel of Zambia (HPCZ).
Birth spacing counseling, including for HIV positive couples and pregnant women to be added to CHA’s competencies

31. CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
Provide pregnancy care (ANC) and Life Saving Skills during delivery at point of care
Initiate early ANC follow up by referring to health facilities
pregnancy test
hemoglobin (Hb)
Urine test (using dipstick)
Refer pregnant mothers with high sugar and protein level in their urine.

32. CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
Train and equip CHAs with skills to:
Conduct emergency delivery procedures (not as routine service), in addition to referring mothers to deliver at health facilities.
Provide misoprostol in emergency situations

33. CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
4. Postpartum care- at household level:
CHAs to conduct 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

34. CURRICULUM REVIEW- CHANGES TO SCOPE OF WORK
Male reproductive health issues: Promote Voluntary Medical Male Circumcision for infant and adult males at community level and refer to MC providing sites.
Nutrition: integrated approach in all modules
Promote/demonstrate child feeding practices through food preparation using locally available foods.
Anemia- administer iron supplements for pregnant women
Vitamins – administer to malnourished children.
7. HIV: Provide VCT services for adults, children, pregnant mothers…integrated with other services

35. PRIMARY HEALTHCARE PACKAGE FOR CHAS
Disease Prevention & Control Package
Family Health Package
Disease Prevention & Control
Sexual & Reproductive Health
Environmental Health
Maternal & Child Health
Infection Prevention
Insect and rodent control
Home, personal, & food hygiene
Excreta disposal
Solid and liquid waste disposal
Water safety
HIV & AIDS & STIs
Male Circumcision
Malaria (RDTs),
Diarrhea
Epidemics TB
Acute Respiratory Illness (ARI)
ANC visits
PNC visits (6,6,6)
Birth plan
Nutrition during, and after pregnancy
PMTCT
Nutrition and growth monitoring
Immunizations
Hygiene
Adolescent health services
Gender issues
HIV & AIDS prevention (VCT)
Family Planning methods
Minor cuts & infections
Bandages
Emergency care (CPR)
First Aid
Health Education Communication Approaches are cross-cutting
Schools ▪ NHC / community meetings
Churches ▪ Various groups & clubs
Health Education & Communication

36. CURRICULUM REVIEW- RECOMMENDATIONS TO EXPAND SCOPE OF WORK
Recommendations for inclusion to CHA scope of work:
Disease Prevention & Control Package
Create awareness on Gender-based violence and promote its prevention
Promote the new vaccines (H-influenza, Pneumococcal, Rota) and other immunizations for <5 children
Provide First Aid for Poisoning
4. Environmental health: Participate in Community Led Total Sanitation (CTLS) programs and coordinate other CHWs for this program.
KB to fill in
Cancelled ANEMIA, FIRST AID FOR POISONING, as they are not under disease prevention and control package

37. CURRICULUM REVIEW- RECOMMENDATIONS TO EXPAND SCOPE OF WORK
5. Prevention and control of common chronic illness:
Conduct rapid blood glucose test and urine test for sugar to diagnose Diabetes among people with signs and symptoms and refer to health facilities.
Promote health lifestyle and prevention of chronic illnesses like diabetes and hypertension.
Provide adherence counseling for patients on medication for chronic illnesses and refer the “lost to follow up” clients to health facilities for re-start.

38. Thank You
Twa Lumba!
Zikomo!