1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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)

10. 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 to May 2015)
Burial team
Members of the dignified and safe burial teams

11. 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

12. 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

13. 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

14. 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

15. 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 ?????

16. The end What do you advice/suggestions???
Thank you for your wonderful attention!!
What do you advice/suggestions???

17. 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