CHWS IN EBOLA SETTING: SIERRA LEONE EXPERIENCE

Dr Joseph N. KandehDirector, Primary Health Care, Ministry of Health and Sanitationjoeagie90@gmail.com

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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