CHWs in Ebola setting: Sierra Leone EXPERIENCE IGC: Africa Growth Forum 2015: Addis Ababa, Ethiopia (June 29 – July 1) CHWs in Ebola setting: Sierra Leone EXPERIENCE Dr Joseph N. Kandeh Director, Primary Health Care, Ministry of Health and Sanitation joeagie90@gmail.com

Outline of the presentation 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 Country Population - 6.5m: under five pop. - 1,150,500; pregnant women pop - 286,000 (Projection from 2004 census) Administrative division - 4 regions (including Western Area of 69 Local Council Wards ), 12 districts of 149 chiefdoms 40 Hospitals (private and public) and 1,185 (Peripheral Health Units) PHUs 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 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

Confirmed, probable and suspected EVD cases Ebola situation Confirmed, probable and suspected EVD cases Declared EVD outbreak on 23rd, May 2014 All districts, all age group and both sexes are affected with varying degrees 8,611 confirmed cases and 3,545 confirmed EVD deaths (as of 27 May 2015) Heavy loss of health personnel (304 cases and 221 deaths) (25 death/month on average) The Epidemic curve

Impact of Ebola on Health system Health worker infections -25% variance decrease in general utilization rate (distrust of health personnel, fear of contracting EVD…) Immunization: reduced by 50% Increase pressure on supply chain for commodities (competing priorities with EVD + travel restrictions) Rise in teenage pregnancy

Health Sector Recovery Framework   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 and UNICEF UNICEF funding Implementing NGO partners is the main modality of Implementation 2010; iCCM – 2 districts 2012; - National CHWs policy launched - iCCM scaled up in to more districts 2013 - Linked with the PHUs - evolved to include promotion of MNH services - Scaled up in 6 more districts (2 iCCM and MNH; 4 only MNH) 2014 - One more district started implementing the MNH

CHw program in sierra leone 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) 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) Burial team Members of the dignified and safe burial teams

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 Before EVD Link communities to PHUs Facilitate increase in facility utilization Treating as many children as PHUs Reduction in child mortality During EVD CHWs acknowledged as core to primary health care delivery system. CHWs are playing a 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 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 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 (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 What do you advice/suggestions??? Thank you for your wonderful attention!! What do you advice/suggestions???

Acknowledgment 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