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

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

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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: 1. 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 =

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

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

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

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

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.

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

CURRICULUM REVIEW- CHANGES 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

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

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

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

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.

Thank You Twa Lumba! Zikomo!