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CHWS IN EBOLA SETTING: SIERRA LEONE EXPERIENCE
Dr Joseph N. KandehDirector, Primary Health Care, Ministry of Health and [email protected]
1
IGC: Africa Growth Forum 2015: Addis Ababa, Ethiopia (June 29 – July 1)
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
EBOLA SITUATION
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)
Confirmed, probable and suspected EVD cases
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
Tracer MCH services at PHU level
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%
-47% -27%
Percent change in number of visits during Ebola (Oct 2014-Jan 2015) vs pre-Ebola (Oct 2013- Jan 2014)
-31%U5 children treated for
malaria
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.
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
Health Sector Recovery Framework
CHW PROGRAM IN SIERRA LEONE
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
iCCM in 6 districtsRMNH in other districtsTechnical leadership; MoHS
and UNICEF UNICEF funding Implementing
NGO partners is the main modality of Implementation
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
Burial teamMembers of the dignified and safe
burial teams
Social mobilizationBCC 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)
CHW INTERVENTION IN THE EVD 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
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.
LESSONS FROM THE EVDDuring 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
Before EVD• Link communities
to PHUs
• Facilitate increase in facility utilization
• Treating as many children as PHUs
• Reduction in child mortality
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
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