Transcript Russia - CORE Group

Assessing and Counting
Functional Community
Health Workers
Lauren Crigler
Director, Workforce Development
HCI Project
Dr. Troy Jacobs, USAID
October 8, 2009
1
Meeting Agenda
• Introduction
– Context and objectives
– Tool components and process
• Nepal Experience
– Implementation of tool
– Validation process
– Lessons Learned
• Next Steps
– Next country testing
• Feedback and Discussion
2
USAID HEALTH CARE IMPROVEMENT PROJECT
Global Context
• Increased research on evidence-based
interventions that can be delivered at community
level (eg. newborn sepsis and pneumonia)
• Increased research on CHWs and Community
Case Management (CCM)
• Guidelines on task-shifting
• Increased resources dedicated to primary and
community health
• Greater collaboration between multilateral and
bilateral organizations
3
USAID HEALTH CARE IMPROVEMENT PROJECT
Congressional Mandate to USAID
• As a key element to scale up effective maternal,
child and newborn interventions, host governments
will increase the number and improve the
functionality of community health workers.
– Currently over 30,000 CHWs in 16 priority countries have
been supported by USAID but what does that mean?
• USAID will assist host governments in priority
countries such to address the MCH human
resources crisis by developing a tool to improve the
functionality of community health workers
programs.
4
USAID HEALTH CARE IMPROVEMENT PROJECT
CHW-PFA Objectives
• Assess the functionality of CHW programs in
maternal/child health
• Count the number of community health workers
within programs assessed as functional
• Assist in action planning and resource allocation to
strengthen CHW programs
5
USAID HEALTH CARE IMPROVEMENT PROJECT
Benefits of this Tool
Allows host governments to:
• Quickly and efficiently assess current and future
programs based on organizational best practices
• Offers a framework for improvement with an
action plan, resources and technical assistance
• Plan for future investment of resources to improve
CHW programs
6
USAID HEALTH CARE IMPROVEMENT PROJECT
Constraints of this Tool
• Does not evaluate the quality of MCH services
delivered by individual health workers
• Does not evaluate CHW contribution to overall
coverage, effectiveness or impact
• Applies most common best practices
• Relies on secondary evidence and self-report for
documentation
7
USAID HEALTH CARE IMPROVEMENT PROJECT
Elements of the Tool and Assessment
Process
•
•
•
•
•
•
•
•
8
Definitions
Programmatic components
Scoring
Applying the draft tool
Stakeholders and documentation
Assessment process
Coming to consensus
Resources
USAID HEALTH CARE IMPROVEMENT PROJECT
Operational Definition of a Community
Health Worker Who Provides MCH Services
A community health worker
is a health worker that
performs a set of essential
MCH health services who
receives standardized training
outside the formal nursing or
medical curricula and has a
defined role within the
community and the larger
health system.
9
USAID HEALTH CARE IMPROVEMENT PROJECT
Defining Maternal Child Health Services and
Interventions
• To be a functional CHW who provides MCH
services, the CHW’s tasks must include at least one
complete key MCH intervention (listed in table 2 of
the tool).
• The list of interventions is adapted from the key
MCH interventions listed in USAID’s Report to
Congress: Working Toward the Goal of Reducing
Maternal and Child Mortality (USAID 2008).
10
USAID HEALTH CARE IMPROVEMENT PROJECT
Maternal Child Health Services and
Interventions
• Interventions are grouped into the following
categories:
–
–
–
–
–
–
–
Antenatal
Childbirth and Immediate Newborn Care
Postpartum and Newborn Care
Early childhood (0-5 yrs)
Family planning/healthy timing and spacing of pregnancy
Malaria*
PMTCT*
*Optional- Dependent Upon Country
11IMPROVEMENT PROJECT
USAID HEALTH CARE
Programmatic Components
The CHW-PFA proposes 12 programmatic components
for a CHW program to be effective:
•
•
•
•
•
•
•
Recruitment
The CHW Role
Initial Training*
Continuing Training*
Equipment and Supplies
Supervision*
Evaluation*
•
•
•
•
•
Incentives
Community Involvement
Referral System
Professional Advancement*
Documentation, Information
Management*
* Modified after testing in Nepal
12
USAID HEALTH CARE IMPROVEMENT PROJECT
Scoring for Program Functionality
•
•
•
13
Four levels of functionality are defined from 0
(non-functional) to 3 (highly-functional) with level 2
considered as minimally functional
Each level describes a situation common to CHW
programs and provides detail to allow
stakeholders to identify where their programs fall
Level 3 provides an accepted best practice for
each component; resources and tools to aid
implementers in achieving that level of
functionality are available in the tool
USAID HEALTH CARE IMPROVEMENT PROJECT
Scoring for MCH Interventions
• One complete intervention requires a check mark in
the column titled YES.
• If intervention has key subcomponents, all
subcomponents of intervention must be completed
for a YES rating.
• Comment box is provided to describe the
intervention more fully or to make notes for action
planning.
• PMTCT and Malaria are in addition to core MCH
interventions
14
USAID HEALTH CARE IMPROVEMENT PROJECT
Applying the CHW-PFA
• Tool is designed to use during a short (half-day)
workshop
• Programs selected should be organizationally
consistent
• Best applied by a diverse group of no more than 15
people (can be as few as 5) from an organization or
CHW program
• Includes individual and group assessment of
components
15
USAID HEALTH CARE IMPROVEMENT PROJECT
Validate the process for improving program
functionality
• Provides an opportunity for shared learning and
action to improve performance
• Establishes a common framework and aims for
CHW programs
• Developing an explicit action plan with follow up
and re-application of the tool
• Encourages accountability and transparency in
programs
16
USAID HEALTH CARE IMPROVEMENT PROJECT
Stakeholders and Documentation
• Participants:
– Field level managers
– District level managers
– CHW supervisors and/or
CHWs if possible
– Other individuals familiar
with the implementation of
the program
17
Documents (as available):
– Job/role descriptions
– Process followed to identify
and recruit
– Documentation of supplies
(frequency, minimum stock)
– Training records (numbers,
content, process)
– Supervision or monitoring
process
– Records of current # of CHWs
– Any other documents available
and pertinent to program
components
USAID HEALTH CARE IMPROVEMENT PROJECT
Assessment Process and Coming to
Consensus
• Participants review each component and discuss the rating
scale as a group.
• Participants are then given time to complete the assessment
on their own.
• Once individual assessments are completed, groups discuss
scores for each component by recording individual scores on
a flip chart and identifying outliers
• Outliers can either justify their score by producing evidence or
come into agreement with the rest of the group.
• If agreement cannot be reached, the lower score is applied
• Final scores are posted and presented
18
USAID HEALTH CARE IMPROVEMENT PROJECT
Action Planning
• Tool can be used with action planning through existing groups
and implementers
• Can be used in conjunction with other tools & approaches for
capacity development and quality improvement (REFLECT,
PDQ, COPE, Learning for Performance, Improvement
Collaboratives, etc)
• Strengthen existing groups, committees, and management
structures using improvement methods - focused on gaps and
on linking management structures, health facilities, and
community
19
USAID HEALTH CARE IMPROVEMENT PROJECT
Re-applying the Instrument
• CHW-PFA can be applied every six months to reevaluate minimum requirements or to count new
CHWs
• To qualify as newly functional, scores should be
reviewed by multiple stakeholders and evidence
produced or discussed that justifies a revision of an
earlier score
• For new or additional CHWs to be added to a
program, they must have completed the initial
training component and successfully integrated into
a current program
20
USAID HEALTH CARE IMPROVEMENT PROJECT
Nepal Experience – June 2009
USAID HEALTH CARE IMPROVEMENT PROJECT
Nepal Community Health Worker Program
Background
• CHW programs started in 1988
• MCH focus
– Adding newborn sepsis management and resuscitation to
core program
• 50,000 Female Community Health Volunteers
(FCHVs) in 75 districts
22
USAID HEALTH CARE IMPROVEMENT PROJECT
Testing in Nepal
• Team:
– Deepak Paudel –
USAID/Kathmandu
– Lauren Crigler - HCI
– Sujan Karki – NFHP
– Troy Jacobs –
USAID/Washington
• Two districts
– Workshop
– Validation
• Focus on FCHVs, but also
AHW, MCHWs/VHWs
USAID HEALTH CARE IMPROVEMENT PROJECT
Banke District
24
USAID HEALTH CARE IMPROVEMENT PROJECT
Banke District Assessment
• 19 participants
– 2 AHW; 4 VHW; 5 MCHW; 3 FCHV; 2 DPHO
– Included members of MGs and HFOMCs
– Partners included CRS, FHI, NFHP
• Discussion was rich and engaged
• Ratings were done on all cadres with main
differences in recruitment and incentives
– FCHVs
– MCHW/VHWs
• Overall programmatic ratings: FCHVs = 18 (16)
MCHW/VHW = 16 (16)
• MCH Interventions – only ANC assessed (3) (1)
25
USAID HEALTH CARE IMPROVEMENT PROJECT
Kavre District
26
USAID HEALTH CARE IMPROVEMENT PROJECT
Kavre District Assessment
• 16 participants
– 3 ANM; 3 VHW; 1 MCHW; 1 SrAHW; 3 FCHV; 3 DHO;
WDO
– Included members of MGs and HFOMCs
•
•
•
•
•
•
•
27
Discussion was rich and engaged
Ratings were done on FCHV cadre only
Completed assessment process
Programmatic functionality: FCHVs = 17 (16)
Number of MCH Interventions = 13 (1)
Total functionality score = 29 (17)
Number of CHWs counted: 837 (Govt) + 191
(NGOs) = 1028 total
USAID HEALTH CARE IMPROVEMENT PROJECT
Validation Interviews and Site Visits
• In Banke, two teams visited separate sites
– Team 1: Kachanapur SHP
• Interviews - 2 FCHVs, 1 VHW at SHP & home
– Team 2: Mahadevpuri SHP
• Interviews – 1 In-Charge, 2 FCHVs, 1 VHW, 1 MCHW
at SHP & homes
• In Kavre, team visited very rural site –
Kosidekha SHP
• Interviewed - 1 In-Charge (AHW), 1 MCHW (recently
ANM), and 2 FCHVs at SHP
28
USAID HEALTH CARE IMPROVEMENT PROJECT
Validation Findings
• Site visits and interviews were conducted
following each assessment workshop
• Information collected during validation process
upheld assessment findings from workshops
– Overall ratings of components were consistent with
findings from interviews
– Validation interviews provide richness and depth to
assessment
29
USAID HEALTH CARE IMPROVEMENT PROJECT
Facilitated Exercise Findings
• Logistics
– Right mix in terms of time and involved stakeholders
• May need more time to complete (eg. Banke/scoring,
presentation of evidence not done as intended)
• Broader stakeholder array in Kavre
• Interpretation/translation issue
• Exercise outcome
– Role of final score & counts
– More work needed on validation of group’s findings from
tool – what a score means/makes sense
30
USAID HEALTH CARE IMPROVEMENT PROJECT
Findings and Suggestions
• Generally, tool was well-received and provided an
opportunity for rich discussion. Some suggestions
for improvements were made:
• Programmatic components
– Professional advancement
– Documentation, information management
• MCH interventions
– Separate counseling/health education/BCC from service
on some items
– Clarify counsel & refer vs. treat & refer
– Separate out standard MCH interventions from malaria
and HIV
31
USAID HEALTH CARE IMPROVEMENT PROJECT
Our Impressions
• Process of assessment works well and provides
great opportunity for learning and action
planning
• Clarification of levels, components, and
interventions will simplify assessment process
32
USAID HEALTH CARE IMPROVEMENT PROJECT
Next Steps
• Further testing
– Francophone Africa (Benin, Rwanda or Senegal)
– Afghanistan ?
– Other regions, countries
• “Finalize” & disseminate in 2010
– Wider use may identify additional incremental changes to
tool in 2010.
33
USAID HEALTH CARE IMPROVEMENT PROJECT
Opportunity for Feedback and Thoughts
?
34
USAID HEALTH CARE IMPROVEMENT PROJECT
Thank you
Lauren Crigler, Director of Workforce Development , HCI
[email protected]
35
35