COMMUNITY HEALTH POLICIES AND PROGRAMMES...6 Community health policies and programmes List of...

ANALYSIS REPORT

COMMUNITY HEALTHPOLICIES AND PROGRAMMES

Publication: October 2019© cover photo: Tremeau/Fonds Français Muskoka

COMMUNITY HEALTHPOLICIES AND PROGRAMMES

ANALYSIS REPORT

Community health policies and programmes4

AC Care community agents (in French: Agents communautaires - Sénégal)

ACPP Prevention and Promotion Community Actor (in French: Acteur Communautaire de Prévention et de Promotion - Sénégal)

ACT Artemisinin-based combination therapy

ANC Antenatal Care

APP Agents for Promotion and Prevention (in French: Agents pour la Promotion et la Prévention - Niger)

ARI Acute Respiratory Infection

ASACO Community Health Organizations (Mali)

ASBC Community-based health workers (in French : Agent de santé à base communautaire - Burkina Faso)

BEPC First Secondary school diploma in francophone education systems - 14/15 years old (in French: Brevet d’Etudes du Premier Cycle)

CAC Community organization unit (in French: Cellule d’animation communautaire - DRC)

CBC Community Birth Companion (The Gambia)

C4D Communication for Development

CHA Community Health Assistant (Liberia)

CHEW Community Health Extension Worker (Nigeria)

CHO Community Health Officer (Ghana)

CHV Community Health Volunteer (Ghana, Liberia)

CHN Community Health Nurse (Gambia, The)

CHW Community Health Worker

CMHO Community Mental Health Officers (Ghana, Cameroun)

CORP Community Oriented Resource Person (Nigeria)

CPN Consultation Prénatale

CSCOM Community Health Center (Mali)

DEF End of Primary school diploma in Mali - 8/9 ans (in French: Diplôme d’Etudes Fondamentales)

DFID Department for International Development

DHIS2 District Health Information Software (Version 2)

DOT Directly Observed Therapy

DSDOM Home healthcare provider (in French: Dispensateur de Soins à Domicile - Senegal)

EBV Epstein-Barr virus

ECD Early Childhood Development

EMTCT Elimination of mother-to-child transmission of VIH

FGM Female Genital Mutilation

GAC Global Affairs Canada (ex-CIDA)

HPV Human papilloma virus

iCCM integrated Community Case Management

IMCI Integrated Management of Childhood Illness

IPTp Intermittent preventive treatment in pregnancy

KMC Kangaroo Mother Care

LGA Local Government Area (Nigeria)

LLI(T)N Long-lasting insecticidal(-treated) nets

LMIS Logistics management and information system

MAM Moderate acute malnutrition

M&E Monitoring and Evaluation

MNP Micronutrient powders

MOH Ministry Of Health

MUAC Mid Upper Arm Circumference

ORS Oral Rehydratation Solutions

PBF Performance-Based Financing

PHC Primary Health Care (The Gambia)

PHU Public Health Unit (Sierra Leone)

PMTCT Prevention of mother-to-child transmission of VIH

RDT Rapid diagnostic tests (malaria)

RECO Community volunteer (RDC)

RUTF Ready-to-Use Therapeutic Food

SAM Severe acute malnutrition

SCP Seasonal malaria chemo-prevention

UNFPA United Nations Population Fund (UNFPA)

TBA Traditional birth attendant (in French: Sage-femme traditionnelle)

VHW Village Health Worker (Gambia, The, Liberia, Guinea)

WCAR West and Central Africa Region

WHO World Health Organization

ACRONYMS

UNICEF - West and Central Africa 5

CONTRIBUTORS AND ACKNOWLEDGMENTS

This work was initiated and coordinated by Magali Romedenne (Community Health Specialist, UNICEF West and Central Africa Regional Office), under the oversight of René Ekpini (Health Regional Adviser, UNICEF WCARO). The desk review, data collection, analysis and reporting were carried out by Leslie Dubent (Public Health Consultant, UNICEF WCARO).

The country teams of respondents were composed of staff from the Ministry of Health (MOH) and UNICEF Country Offices. These included the following members in the twenty countries: Benin: Denis Sossa (MOH), and Gilbert Vissoh, Soliou Badarou, Adama Ouedraogo (UNICEF); Burkina Faso: Neya Christelle Ouédraogo, Valérie Zombré Sanon, Daouda Akabi, Kafando Awa Ouédraogo, Yaméogo Issaka (MOH) and Denis Bakunzi Muhoza, Yemdame Bangagne (UNICEF); Cameroon: Manjo Mathilda (MOH) and Grégoire Kananda, Augustin Rashidi Maulidi Amboko (UNICEF); Central African Republic: Oscar Bekaka Youle Dobinet, Aimé Théodore Dodane (MOH), and Emmanuel Wansi, Faton Mehoundo (UNICEF); Chad: Mahamat Tidjani Ali, (MOH), and Célestin Traoré, Thomas Morban, Marie Claire Mutanda, Morgaye Gueim, Mamadou N’Diaye (UNICEF); Côte d’Ivoire: Simplice Dagnan, Mamadou Samba, Adama Sanogo Pongathie (MOH) and Bechir Aounen, Bruno Aholoukpe, Alimata Diakite Sow (UNICEF); Republic of Congo: Ludovic Gnekoumou Libaba, Gabrielle Ossenza, Daniel Mfoutou, Josh Mberi, Paul Nzaba (MOH) and Hermann Boris Didi Ngossaki, Mayeul Patrick Moukoulou Lwamba, Belem Elisabeth Kiendrebeo (UNICEF); The Gambia: Musa. M. Loum, Ebrima Bah, Modou Njai, Haddy Badjie, Kausu Bojang, Fatou O Sowe, Ousman Ceesay, Lamin B. Jawara, Modou Njie, Alhagie Sangareh, Ngally Abubacarr Sambou, Baba Galleh Jallow, Lamin Ceesay, Modou Njie (MOH) and Mariama Janneh (UNICEF); Ghana: Charles Adjei Acquah, Koku Awoonor (MOH), and Daniel Yayemain (UNICEF); Guinea: Facinet Yattara, Emmanuel Roland Malano (MOH); Guinea Bissau: Pedro Vaz (MOH), and Jean-Claude Mubalama, Umaro Ba, Sofia De Oliviera, Zaira Rodriguez (UNICEF); Liberia: Tamba Boima (MOH), and Anthony Yeakpalah, Anju Puri (UNICEF); Mali: Maiga Oumou Maiga, Plea Boureima (MOH), and Samba Diarra, Sekou Oumar Diarra (UNICEF); Mauritania: Aly Cheibany Cheikh Ahmed (MOH), and Kalidou Samba Ba (UNICEF); Niger: Soughia Mariama, Hamidou Atta (MOH), and Mariam Sylla Diène, Awa Seck, Fatima Hachimou (UNICEF); Nigeria: E. Meribole, Anthony Adoghe (MOH) and Fatima Cheshi (UNICEF); Democratic Republic Of Congo: Moise Kakule Kanyere, John Tony Bakukulu (MOH) and Tony Byamungu, Rie Takesue (UNICEF); Senegal: Khady Seck, Fatou Berete Ndiaye Niang, Amy Mbacké, Alioune Tall, Anta Diaw, Sadiya Aidara (MOH), Hassane Yaradou(USAID), Judith Tsague (MEASURE), and Aida Gadiaga (UNICEF); Sierra Leone: Alpha Bangura, Joseph Bangura (MOH), and Hailemariam Legesse (UNICEF); Togo: Abdoukarim Naba Mouchedou (MOH), and Marie Therese Guigui, Akouété Afanou (UNICEF).

UNICEF resources supported the funding for the coordination of the work. In addition, financial support for the consultancy work, as well as its publication was received from The French Muskoka Fund. This financial support is gratefully acknowledged.


List of figures 8List of tables 9List of boxes 9

Executive summary 10Context 11Objectives 12Methods 13Results 141. COORDINATION AND POLICY SETTING 14

1.1. Policy and strategic documents 141.2. Key principles 141.3. Situation analysis 151.4. Coordination mechanisms 151.5. Population coverage of the program 161.6. Communication and social mobilization 16

2. COSTING AND FINANCING 182.1. Costing 182.2. National budget 182.3. Cost of services 182.4. Donors funding 18

3. HUMAN RESOURCES 193.1. Status as described in policy documents 193.2. Multiplicity of CHWs types 213.3. Status and means of recognition 233.4. Remuneration 253.5. Retention strategy 263.6. Educational background and training 273.7. Density 28

4. GENDER RESPONSIVENESS 304.1. Policy review 304.2. Gender balance in recruitment 304.3. Gender-specific advantages/disadvantages 304.4. Gender-responsiveness of policy documents 31

5. PACKAGE OF SERVICES 325.1. Definition of package of services in policy documents 325.2. Antenatal and newborn care 325.3. Childhood illnesses 345.4. Adolescent health 365.5. Family planning 375.6. HIV 385.7. Tuberculosis 395.8. Community-based surveillance 39

TABLE OF CONTENTS


6. SUPPLY CHAIN MANAGEMENT 416.1. Supply plans 416.2. Integration into national supply system 416.3. Appropriate medicines for community case management 42

7. REFERRAL AND COUNTER-REFERRAL 437.1. Definition of referral and counter-referral mechanisms in policy documents 437.2. Existence of clearly define mechanisms 437.3. Counter-referral 43

8. COMMUNICATION AND SOCIAL MOBILIZATION 448.1. Communication 448.2. Community engagement 448.3. Accountability framework 448.4. Community capacities 448.5. Multisectoral dynamic at community levels 45

9. SUPERVISION AND PERFORMANCE QUALITY ASSURANCE 469.1. Policy review 469.2. Supervision and performance quality assurance practices in countries 46

10. MONITORING AND EVALUATION AND COMMUNITY HEALTH INFORMATION SYSTEMS 49

10.1. Policy review 4910.2. Monitoring framework 4910.3. Integration of community health data into national information system 4910.4. Research plans 50

Discussion 51Conclusion 53References 54

ANNEX A - Country Profiles 56ANNEX B - Regional Profile 76ANNEX C - Tables of main community health criteria in West and Central African countries 78ANNEX D - Questionnaire 105

TABLE OF CONTENTS


Figure 1- Overall number of available official strategic community health documents in 20 WCAR countries 14

Figure 2- Number of WCAR countries addressing the community health key principles in policydocuments, by level 15

Figure 3-Civil servant and contractual CHWs in WCAR countries 19

Figure 4- Volunteer CHWs in WCAR countries 19

Figure 5- CHWs salary and motivation in WCAR countries 20

Figure 6- Distribution of community workers statuses in WCAR countries 23

Figure 7- Number of WCAR countries implementing the different modes of remuneration for each category of workers 25

Figure 8- Number of WCAR countries according to the educational level required, for each category of workers 27

Figure 9- Distribution of number of WCAR countries according to training duration ranges for category 1 workers 27

Figure 10- Distribution of refresher training periodicity for category 1 workers by number of WCAR countries 28

Figure 11- WCAR countries where are found gender-balanced pairs of CHWs or predominance of women 30

Figure 12- Number of WCAR countries implementing each component of the package of services 32

Figure 13- Geographic coverage of ANC full implementation in WCAR countries 33

Figure 14- Geographic coverage of ANC partial implementation in WCAR countries 33

Figure 15- Number of WCA countries where CHWs provide the different promotional ANC services 33

Figure 16- Number of WCA countries where CHWs provide the different prevention ANC services 34

Figure 17- Geographic coverage of iCCM full implementation in WCAR countries 34

Figure 18- Geographic coverage of iCCM partial implementation in WCAR countries 34

Figure 19- Different promotional childhood illnesses services provided by CHWs in WCAR countries 35

Figure 20- Different prevention childhood illnesses services provided by CHWs in WCAR countries 35

Figure 21- Different curative childhood illnesses services provided by CHWs in WCAR countries 36

Figure 22- Geographic coverage of adolescent services full implementation in WCAR countries 36

Figure 23- Geographic coverage of partial implementation of adolescent health services in WCAR countries 36

Figure 24- Services provided to adolescent by CHWs in WCAR countries 37

Figure 25- Geographic coverage of full implementation of family planning services in WCAR countries 37

Figure 26- Geographic coverage of partial implementation of family planning services in WCAR countries 37

Figure 27- Family planning services provided by CHWs 37

LIST OF FIGURES


Figure 28- Geographic coverage of full implementation of HIV services in WCAR countries 38

Figure 29- Geographic coverage of partial implementation of HIV services in WCAR countries 38

Figure 30- HIV services provided by CHWs in WCAR countries 38

Figure 31- Geographic coverage of full implementation of tuberculosis services in WCAR countries 39

Figure 32- Geographic coverage of partial implementation of tuberculosis services in WCAR countries 39

Figure 33- TB services provided by CHWs in WCAR countries 39

Figure 34- Geographic coverage of full implementation of community-based surveillance 40

Figure 35- Geographic coverage of partial implementation of community-based surveillance 40

Figure 36- Diseases included in community-based surveillance activities 40

Figure 37- Existence of procurement plans for components of the care services planned at community level in WCAR countries 41

Figure 38- Existence of a community engagement plan and where it belongs in the policydocuments in WCAR countries 44

Figure 39- Number of WCAR countries that acknowledge the four specified community capacities 45

Figure 40- Integration of community health data into the national health information system and disaggregation of data 49

Figure 41- Use and stage of implementation of DHIS2 in WCAR countries 50

LIST OF FIGURES

LIST OF TABLES

LIST OF BOXES

Table 1- Designation of main community health workers in WCAR countries 22

Table 2- Time allocation for activities of both CHWs categories in WCAR 24

Table 3- Identity of CHWs supervisors in WCAR countries 47

Box 1- Perspective of policies regarding authorization for CHWs to provide treatment 17

Box 2- Reform of the CHW status - example of Côte d’Ivoire 22

Box 3- Example of Mauritania as a regional exception for sex-ratio 31

Box 4- Innovative patterns for supervision 48


EXECUTIVE SUMMARY

This report presents an overview of community health policies and programs across the 20 countries of West and Central Africa that have a community health program being implemented so far - Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, The Gambia, Togo. This work, conducted by UNICEF West and Central Africa Regional Office (WCARO), envisions an expanded view of community health beyond integrated community case management (iCCM). Drawing from both analysis of policy and strategic documents of all the 20 countries, and a survey that targeted Ministry of Health of these countries, this report highlights the main strengths and weaknesses of community health programs in the region, based on the 8 benchmarks and criteria established for community health: i) Coordination and policy setting; ii) Costing and financing; iii) Human resources, including their package of services; iv) Supply chain management; v) Service delivery and referral; vi) Communication and social mobilization; vii) Supervision and performance quality assurance; and viii) Monitoring and Evaluation and Community Health Information System. This work contributes to documenting community health policy and implementation challenges and progresses and will be critical to inform community health strategy and policy in this area at regional and national level.


In order to address the challenge of population coverage for basic health services, programs and interventions bringing life-saving services closer to the population have developed, and it no longer needs to be proven that community-based healthcare delivery and Community Health Workers (CHWs) represent an effective strategy to increase access to care and treatment for children, thus contributing to equity and reduction of child mortality [1, 2, 3]. Community health is critically growing in national priorities and 20 countries of the region1 (out of 24) have a community health program. Moreover, tendency towards institutionalization of community health has been marked by the Institutionalizing Community Health Conference (ICHC) held in Johannesburg, South Africa, in March 2017. Ten principles were then established regarding, among other points, community engagement, human resources with strong and recognized community health workforce, financing, policies, integration of community data in the health information system [4]. However, integration of community health systems into national health systems still remains controversial sometimes. Therefore, clarification is needed whether community case management (CCM) is a palliative system while health facilities are being reinforced to provide effective coverage, or whether CCM and CHWs represent a permanent solution to provide services, which will impact financing and its sustainability [5]. Also, despite many challenges, most countries have developed a written document for CCM, but high-level policies are not the most common basis [6, 7]. Moreover, advances are not equal in all countries and important differences can be highlighted regarding policy, coordinating structure, package of services offered, geographical coverage, and status of CHWs [6].

In this context, UNICEF West and Central Africa Regional Office (WCARO) is working on orienting community health programming in the region and at national level, aiming at ensuring access to quality services to the most deprived children and families. To document this work, a broad review of community health policies, implementation mechanisms, and scope is being carried out.

The first step of this work consisted in a desk review aiming at examining all policy documents - policies, strategic plans, implementation plans, and guidelines - of the 20 countries of the region that have a community health program. This desk review, analyzing policies according to the eight benchmarks for integrated Community Case Management (iCCM) [2], has highlighted differences both in terms of content and robustness of policies between the countries. It has also underlined on the one hand some interesting strategies and on the other hand some weaknesses within community health policy. Also, one policy document or even one country set of policy documents hardly ever describes and takes into account all essential policy aspects.

This is where the survey on community health policies stands, aiming at further exploring and assessing the policy aspects broached in the policy documents, and to verify consistency between the policies and their enforcement. The survey also falls within a previous assessment work conducted by UNICEF in 2013 in 45 sub-Saharan African countries that explored CCM of childhood illness, including CHWs status and activities, and iCCM policy and financing [6].

This report presents and puts in perspective both the findings from the desk review and the 2018 survey.

CONTEXT

1. Benin, Burkina Faso, Cameroon, CAR, Chad, Congo, Côte d’Ivoire, DRC, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, The Gambia, Togo.


OBJECTIVES

The general objective of the survey is to provide a 2018 overview of community health policy and implementation in the 20 countries of the region that have a community health program.

The specific objectives are to:

- -Further explore the content of the policies regarding the eight iCCM benchmarks (following the policy documents analysis);

- Compare contents of policies among countries;

- Sort countries by categories, according to their level of institutionalization;

- Develop country profiles;

- Identify the tendencies regarding institutionalization of community health in countries and set a baseline to later monitor progress towards this institutionalization.


1. Desk review The 20 UNICEF Country Offices (COs) of the region - in the countries having a community health program - have been asked to share all the country’s community health policy documents currently applicable, and when such documents did not exist, the documents that rule community health or at least the ones that refer to community health aspects.

Given the important number of documents, we chose to focus on policies, strategic plans, implementation/action plans, and guidelines; and other documents only where these ones were not available in the country.

Policy documents content was analyzed based on the 8 iCCM benchmarks, namely:- Coordination and policy setting- Costing and financing- Human resources- Supply chain management- Service delivery and referral- Communication and social mobilization- Supervision and performance quality assurance- Monitoring and Evaluation and Community

Health Information Systems

Relevant data (according to these 8 benchmarks) were extracted from policy documents and entered in a table. First, findings were analyzed through the 8 benchmarks for each country. Then, a second analysis compared findings from all countries on the basis of these 8 benchmarks.

2. SurveyThe desk review previously carried out allowed to highlight some strengths and weaknesses, as well as essential aspects needing to be further explored within the policies. Built on both these findings and previous surveys of iCCM policy and implementation, a tool has been developed. The latter includes 58 questions, divided into nine sections, reflecting the eight benchmarks of community health [2], as above:

This survey explores community health systems, including management of cases beyond iCCM diseases (i.e. malaria, pneumonia, and diarrhea) and community ownership.

The questionnaire was sent by email to the 20 UNICEF country offices (COs) in the region - not including Cape Verde, Equatorial Guinea, Gabon, and Sao Tome & Principe that do not have a community health program. COs were made responsible for having the survey completed in a collaborative way by the national community health committee2, or a narrowed group, and imperatively validated by the Ministry of Health. All the completed questionnaires were received by March 2018. Data entry, triangulation, data cleaning, and verification have been undertaken between December 2017 and April 2018. Triangulation was made through comparison with policy documents and clarification sought from the UNICEF COs respondents when needed. Verification included missing values and consistency of the responses.

Analysis was performed through i) basic quantitative assessment using Microsoft Excel 2013; and ii) content analysis of qualitative responses.

METHODS

2. National community health committee usually includes main stakeholders of community health in the country: several Directions/Divisions within the Ministry of Health, other ministries, Technical and Financial Partners, private sector, research institutes, etc.

A cross-sectional descriptive survey was undertaken at the WCARO level.


1. COORDINATION AND POLICY SETTING

1.1. Policy and strategic documentsAmong the 20 countries, 18 have shared at least one community health specific policy document - policy, strategic plan, action plan, or guidelines. Overall, we gathered 10 policies, 13 strategic plans, and 9 implementation/action plans or guidelines. 12 countries, out of the 20 surveyed, have stated to have an official community health policy, 17 a strategic plan, 10 action plans, and 14 implementation guidelines. It should be noted that Democratic Republic of Congo’s (DRC) policy concerns the broader primary health care but development of a community health strategic plan is underway. The Gambia do not have an official document yet either, but community health dimensions are integrated in the National Health Policy (2014-2020) and community health policy is planned to be developed by 2019.

Figure 1- Overall number of available official strategic community health documents in 20 WCAR countries

12

17

10

14

2

Policy

Strate

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Action

plan

Imple

men

tatio

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guide

lines

Develo

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in pr

ogre

ss

We noticed that half of all policies (5 in 10) and about 70% of strategic plans (9 in 13) date from 2016 or later, which highlights an overall recent reinforcement of the commitment towards Community Health.

Generally, the political orientation associates long and middle term approaches: the policies generally do not cover a specific period whereas 84% of strategic plans do, and more than 60% of them are quinquennial ones.

The policy setting is often evidence-based since 80% of countries (16 in 20) have based their policy upon a situational analysis, and among them three (Niger, Senegal, and Sierra Leone) have carried out a mapping of partners.

Finally, 70% of countries (14 in 20) have a community health coordination structure within the Ministry of Health, and 75% (15 in 20) have a national multidisciplinary committee, which indicates that policy environment is obviously marked by strengthening of coordination and multidisciplinary approach.

1.2. Key principlesCommunity health programs are based on some essential principles that are stated in the policy or other strategic documents. The desk review allowed to highlight the most important and recurrent principles. In the survey, for each principle - equity, gender equality, community engagement, local governance, accountability, sustainability, multi-sectoriality - countries have been asked to position themselves by choosing whether either the principle is not mentioned in the policy documents, barely mentioned, clearly specified, or monitored through indicators. Graph 2 illustrates the number of countries addressing by level each key principle in the policy documents.

All the 20 countries surveyed submitted the filled questionnaire, responded by a national committee, sometimes a narrowed group, but in all cases validated by the Ministry of Health. Compared to the previous survey conducted in 2013, the same countries in the region, with addition to Guinea Bissau that has now a community health program implemented, submitted the questionnaire.

RESULTSCoordination and policy setting


Figure 2 - Number of WCAR countries addressing the community health key principles in policy documents, by level

4 2

1 3

5

2 3

4 5

2

14

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14 13 13

11 13

3 3 4 4

3 2

4

Equity

Gende

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Comm

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enga

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Accou

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Susta

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Mult

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barely mentionedmonitored

through indicators

clearly specifiednot mentionedin policy documents

As demonstrated in the figure 2, most key principles are clearly specified in the policy documents, with gender equality being the least principle reflected:

Equity is integrated in the community health official documents and monitored through indicators in three countries; it is clearly specified in 14 countries, and finally only mentioned in the documents in three other countries.

Gender equality is monitored in three countries, clearly specified in eight, mentioned in five, and not mentioned at all in four countries documents (Benin, Guinea, Mauritania, and Senegal).

Community engagement is monitored in four countries, clearly specified in 14 countries, and just mentioned in the documents in two countries.

Local governance is a principle monitored in four countries, clearly specified in 13, and mentioned in the three others.

Accountability is monitored in three countries, clearly specified in 13, and barely mentioned in the four left.

Sustainability is not mentioned in Chad and Congo documents, just mentioned in five countries, clearly specified in 11, and indicators allow to monitor it in two countries.

Multi-sectoriality is not mentioned in Congo documents, barely mentioned in two countries, clearly specified in 13 others, and finally monitored through specific indicators in four countries.

Burkina Faso and Niger seem to have all essential principles monitored through specific indicators.

1.3. Situation analysis18 countries have developed their community health policy based on a situational analysis, whereas Cameroon and The Gambia did not. The analysis includes a desk review in 16 countries, a mapping in 11, an evaluation of the program in five, and consultation of experts in 13. Burkina Faso, Niger, and Togo analysis encompassed all of these processes. Other methods have also been cited, such as field survey in Mauritania and Niger, National Forum on Community Health in Benin, or CHWs Forum in Togo.

1.4. Coordination mechanismsAll countries state that a coordinating structure for community health exists at central level within the Ministry of Health. This structure has different names among countries, such as Direction in Burkina Faso, Chad, Congo, Côte d’Ivoire, and Guinea Bissau; Division in Benin and Chad; Service or Section in Mali, Mauritania, Niger; Hub, Cell or Office in Cameroon, DRC, Senegal, or Sierra Leone; Steering committee or Coordination in CAR, The Gambia, Ghana, Liberia, Nigeria, or Togo.

A multisectoral committee exists in 13 countries. Its composition almost always includes several units of Ministry of Health, other ministries, and technical and financial partners, and less often representatives of the private sector and research institutes. This multisectoral committee



has a programmatic role and acts as platform for exchange in all of the 13 countries, but the decision-making role of the committee is admitted in only 10 countries. Such a committee does not exist in Benin yet, but it is described in the policy document. In Côte d’Ivoire, a committee does not exist either, but actions are coordinated by Technical Working Groups (TWGs) bringing together all the stakeholders, and whose meetings are set up regularly according to the needs of the moment. In Chad, two committees seem to co-occur: the national community health steering committee and the committee for monitoring implementation of community health strategic plan.

Regarding the frequency of meetings, the committee meets once a month in four countries, quarterly in four others, and every six months in the five left. Mauritania specifies that a narrow committee meets once a month and meetings at a larger extent occur every six months. Actually, as a matter of fact, meetings are deemed to be operative in only 9 countries.

1.5. Population coverage of the programThe scale of coverage of the community health program, as well as the vision of the policy for the planned coverage vary widely among countries. Some of them plan to cover the whole national population with community health services - Benin, Burkina Faso, Central African Republic (CAR), Congo (targeting all children under five and women of reproductive age), DRC (covering the whole territory with 170,000 community organization unit3), The Gambia, Guinea Bissau, Mauritania, and Sierra Leone, whereas others have lower immediate ambition, such as Mali that is planning to cover 40% of the population by 2017 and 60% by 2020, and Chad that targets, by 2018, 11 regions out of 23 with 2,000 CHWs focusing on tuberculosis, malaria, and HIV (The Global Fund funding), in addition to the five regions piloting Results-Based Financing (World Bank funding).

1.6. Communication and social mobilization

Out of the 20, 11 countries say they have a communication and social mobilization plan. However, none of them have such a plan specific to community health, as it is included in a wider one such as maternal and child health communication or even health communication strategy. Elaboration of a community health specific communication plan is in progress in Senegal and planned to be in Benin. Overall, needs for harmonization of communication and social mobilization within the programs are highlighted by almost all countries.


3. Translated from the original French word “cellule d’animation communautaire” (CAC)



Are CHWs authorized to provide treatment? All countries have at least one official document that authorizes CHWs to provide treatment for diarrhea, malaria, or pneumonia - respectively using Oral Rehydration Salts (ORS) and Zinc, Rapid Diagnostic Tests (RDT) and Artemisinin-based Combination Therapy (ACT), and amoxicillin. These documents include official community health policy or strategic documents, national directives, circulars from Ministry of Health, ministerial decrees, etc. However, in Burkina Faso and Guinea this authorization for providing drugs relies only on less formal documents, namely norms and protocols, training modules, and decision trees and algorithms.

Regarding management of severe acute malnutrition with Ready-to-Use Therapeutic Food, CHWs are authorized for it in only nine countries - Cameroon, DRC, The Gambia, Ghana, Guinea Bissau, Mali, Nigeria, and Togo. The documents that refer to it include community health national policy, protocols, directives, or guidelines, except for The Gambia where a specific document have been mentioned as the “Integrated Management of Acute Malnutrition Guideline”.

Cord care using chlorhexidine is part of CHWs services in Cameroon, Côte d’Ivoire, DRC, Ghana, Mali, Nigeria, Senegal, and Sierra Leone. This is endorsed by community health, IMCI, or newborn care strategy documents, or by ministerial decree like in Senegal and Côte d’Ivoire - although Senegal mentions that chlorhexidine solution form has been withdrawn.

Contraceptives are provided by CHWs in several countries based on reproductive health strategic documents - except for CAR, Guinea, Mauritania, and Niger. Also, Benin cites its commitment at the Addis Ababa conference on family planning as a basis for allowing CHWs to provide contraceptives.

Finally, treatment for some other diseases has been mentioned as part of the CHWs package of services, such as leprosy and tuberculosis treatment in The Gambia, and neglected tropical diseases in Togo.

Box 1: Perspective of policies regarding authorization for CHWs to provide treatment


RESULTSCosts and financing

2. COSTS AND FINANCING

2.1. CostingOut of the 20 countries, 16 have costed their community health program - seven countries on a five-year basis, three countries for three years, one for four years, and one for a single year. Estimation ranges between 51,222 US$/5 years in Guinea Bissau and 1,593,314,944 US$/4 years in Chad (cf. annex 2). Costing process is on-going in DRC. CAR, Côte d’Ivoire, and Nigeria have not costed the program yet. Among countries that have estimated the costs, only four countries - Burkina Faso, The Gambia, Guinea, and Sierra Leone - state that the program is secured by a financing plan. Niger and Sierra Leone has recently carried out a community health investment case, and Burkina Faso is ongoing.

2.2. National budgetNine countries notify that a budget line is dedicated to community health within the national health budget; also, one country (Sierra Leone) specifies that this line is donor funded, one that this line only funds CHWs incentives (Burkina Faso), and one only medicines (Mauritania).

Among the countries that had a budget line both in 2016 and 2017, the amount remains stable between the two years in Burkina Faso (3,378,160,000 FCFA), CAR (8,500,000 FCFA), and Togo (80,000,000 FCFA), whereas it has been reduced in Cameroon (from 10,000,000 FCFA to 5,000,000 FCFA). Only three countries estimate the proportion of this budget line within the health budget - 0.0033% in CAR, 1.56% in Burkina Faso, and 16.50% in Sierra Leone. Only Sierra Leone and Togo declare that a plan has been developed by the government to increase the share of this community health budget.

2.3. Cost of servicesConsultations provided by CHWs are free of charge in 15 countries - not in The Gambia, Guinea, and Mauritania. In Senegal free services only concern the ones provided by DSDOM4 to children under five, and in Mali only birth registration and services to the indigents. Medicines and supplies for services offered by CHWs are free of charge in nine countries and sometimes, as in Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Mali, Mauritania, and Senegal, only a few treatments are free such as treatment for malaria, diarrhea, and pneumonia, vitamin A, or family planning.

2.4 Donors fundingAll the 20 countries count UNICEF and The Global Fund as main donors to the community health program; 15 countries count also World Health Organization (WHO) and three countries (DRC, Nigeria, and Senegal) also the Global Affairs Canada (GAC). Among other donors most frequently mentioned are the World Bank, the European Union, Plan International, the Bill and Melinda Gates Foundation, the United Kingdom Department for International Development (DFID) or United Nations Population Fund (UNFPA).

4. DSDOM are home-based care providers in Senegal, initially part of the malaria national program and now also able to provide care for diarrhea and acute respiratory infection.


3. HUMAN RESOURCES

3.1. Status as described in policy documents

ContractOnly one country (Ghana) have civil servant Community Health Workers (CHWs), and Niger has the CHWs institutionalized since they practice in the health huts. Also, according to the policy documents, 4 countries (Benin, Liberia, Mali, and Nigeria) seem to have contractual CHWs, and 16 countries have volunteer CHWs - 6 besides other status and 10 as the only CHW status. Finally, 4 countries do not state at all the status of CHWs in their policy documents.

Figure 3-Civil servant and contractual CHWs in WCAR countries

contractual CHWs

civil servant

Figure 4- Volunteer CHWs in WCAR countries

volunteer CHWs

Only 3 countries have CHWs signing a contract, which is called performance contract in Benin and Mauritania, service delivery contract - renewed on performance - in Guinea Bissau.

Identification45% of countries (9 in 20) provide CHWs with badge and/or identification card; among them, 2 also provide them with a recognizable jacket, and 1 (Côte d’Ivoire) registers them in a national register. Burkina Faso is the only country that uses a jacket for only one CHWs recognition mean. Guinea is planning, according to the policy, to determine a recognition system later on. Finally, 9 countries do not mention at all the recognition question in their policy documents.

Selection criteriaSelection criteria and process are clearly defined in 70% of countries’ policy documents (14 in 20). However, required education level is specified in 15 policy documents.

2 countries require higher education: BEPC and training certificate in nursing and obstetric care in Benin, and DEF and nursing auxiliary or matron certificate in Mali (but only for CHWs, community relays must only be literate). 3 countries require grade-school level - Primary Education Certificate in Burkina Faso, completion of primary education in Guinea Bissau, and completion of 6th grade in Liberia. 10 countries require ability to read and write (and also count in one of them), but among them, 2 accept illiterate people if layperson in a specific expertise area (Côte d’Ivoire) or if a woman (Sierra Leone).

Training Training provided is variable: pre-service training offered vary from 3 (CHVs in Ghana) to 25 days (CHWs in Sierra Leone). According to policy statement, refresher training occurs in 6 countries (Burkina Faso, Côte d’Ivoire, Ghana, Guinea Bissau, Niger, and Sierra Leone). Also, according to policy statement, training plan

RESULTSHuman resources


(including pre-service and refresher trainings) still has to be developed in 4 countries (Benin, Guinea, Liberia, and Senegal).

MotivationA financial motivation is set in 14 countries and varies from 10 000 FCFA/month (Community Relays in Niger) to 70$/month (CHAs in Liberia). The salary notion is found for Skilled CHWs in Benin, CHOs in Ghana, and CHWs in Mali and Niger. Also, in Mali, CHWs are ensured to get monthly Guaranteed Minimum Wage. The notion of motivation is encountered in most countries, and the motivation is perceived on a quarterly or bi-annually basis in Mauritania, and monthly elsewhere.

Figure 5- CHWs salary and motivation in WCAR countries

motivation

salary

The Performance Based Financing (PBF) seems to be implemented in 3 countries (Benin, Cameroon, Côte d’Ivoire), and according to the policy should be explored/piloted in 2 others (Central African Republic and Liberia); in practice PBF is currently being explored/piloted in several countries.

Several special cases can be highlighted here: - In Burkina Faso, CHWs are making profit on

products sale (besides motivation and per diem)

- In Guinea Bissau, the motivation/remuneration of CHWs would be a combination of three sources, namely: i) State (Ministry of Health, Programs), ii) Communities, and iii) fee-for-service

Retention strategy According to the policy documents, a retention strategy for CHWs is in place in 40% of countries (8/20). According to the content exposed in the policy, it seems that the strategy should be consolidated or totally developed for another 35% (7/20). Some examples can illustrate what is found in such strategies:- Facilities for access to care: reduction/free

consultation (Burkina Faso, Cameroon, Côte d’Ivoire, Guinea Bissau, Mali, Niger, Senegal)

- Priority for integrating national campaigns (Cameroon, Liberia, Niger)

- Career development opportunities (Ghana, Liberia, Sierra Leone)

- Community support (Burkina Faso, Cameroon, CAR, Côte d’Ivoire, Guinea Bissau, Mali, Sierra Leone)

- Support for Income Generating Activities (Niger, Togo)

- Honorary Distinctions (Burkina Faso, Cameroon, CAR, Ghana, Guinea Bissau, Senegal, Sierra Leone, Togo)

- Premiums based on performance (Cameroon, Ghana)

DensityThe policy recommended density is differently expressed among the policies and varies from 1 CHW per 40 to 1 per 70 households, and from 1 per 250 to 1 per 500 inhabitants, depending on distance from health facility and status of CHW (CHW/relay). Also, Chad recommends 2 CHWs per village, and Benin one CHW in each village or neighborhood of the country.

Recommended density can vary upon geographical zones (e.g.: Northern and Southern regions in Chad and Mali) or local needs (Nigeria).



Niger’s special case highlights the association of CHWs (responsible for curative services) and Agents for Promotion and Prevention (APP) (responsible for promotional and preventive services), and the recommended density specifies, respectively, 1 CHW per 500 inhabitants and 2 APPs per 300 inhabitants.

3.2. Multiplicity of CHWs typesOut of the 20 countries surveyed, 15 of them have several types of CHWs identified in the national community health policy documents.

Burkina Faso, Guinea Bissau, Mali, and Sierra Leone have only one kind of CHW, named Community-based health workers in Burkina Faso and Community health workers in the three others.

When two types of CHWs are found, most of the time they are CHWs and Relays, like in CAR, Chad, Benin, Guinea, Mauritania, and Togo. The structure is pretty much the same when it comes to Community Health Officers/Assistants (CHOs/CHAs) and Community Health Volunteers (CHVs) in Ghana and Liberia; or Community Health Extension Workers (CHEWs) and Community-Oriented Resource Persons (CORPs) in Nigeria.

Sometimes, the two types of CHWs are actually from different levels of responsibilities, like Relays with standard package of services versus Relays with comprehensive package of services in Congo; or Relays with promotional and preventive package versus Relays with comprehensive package in Niger; or Promotional relays versus Service provider relays (in addition to a third category, related to Health Committee, as Institutional relays in schools, churches, etc.) in DRC. Finally, some examples are more atypical like Basic and Coach CHWs in Côte d’Ivoire, and Promotion and prevention community actors (ACPP) and Care community actors (ACs) in Senegal.

FRONTLINE WORKERS IN WCAR

Community health workers (CHW/ASC)

Community-based health workers (ASBC)

Relays/Relais

Community health officers (CHO)

Community health assistants (CHA)

Community health volunteers (CHV)

Community health extension workers (CHEW)

Community oriented resources persons (CORP)

Basic community health workers (ASC classique

Coach community health workers (Superviseur d’ASC)

Peer-educator community health workers

Promotion & prevention community actors (ACPP)

Case management community actors (AC)

Traditional healers

Traditional birth attendants (TBA/Sage-femme traditionnelle)

Trained traditional midwives/matrones

Community Birth Companion (CBC/doula)

Community mental health officers (Travailleur psychosocial)

Community ophthalmic nurses

Village Health Workers (VHW)

Besides the types of CHWs described above, many countries have other types of workers carrying out health activities at community level, including workers specialized to manage specific diseases. Traditional healers and Traditional Birth Attendants (TBA)/matrons are very widespread, like in CAR, Cameroon, Chad, DRC, Liberia (Trained Traditional Midwives), Mali, and Sierra Leone. We can also mention here eye care services (Nyaterros) and community ophthalmic nurses in The Gambia, and Community Mental



Health Officers (CMHOs) in Ghana. Also, some CHWs may be specialized/dedicated to specific activities, like for instance some CHWs for family planning in Togo, and some Village Health Workers (VHWs) for respectively Guinea worm program and tuberculosis/leprosy program in Nigeria.

The multiplicity of CHWs (when more than two types of them coexist) is deemed to be effective in only four countries. However, only nine countries intend to simplify the organizational scheme in place.

Box 2: Reform of the CHW status - example of Côte d’Ivoire

Reform of the CHW status - example of Côte d’IvoireBased on an analysis of existing CHW statuses worldwide, Côte d’Ivoire decided in 2017 to reform the status of its CHWs. Up to that point, several types of agents existed: relays, mobilizing agents, community counselors, community health workers, community-based contraceptive distribution agents, etc. It was then decided to opt for “community health workers” as the best term to be used, gathering the different types of CHWs, and within which three new categories were defined:

- Basic CHW: CHW providing promotional services (essential family practices, WASH, etc.)

- Peer-educator CHW: CHW providing a complete package of services, including ability for peer counselling due to several years of experience (HIV, tuberculosis, reproductive health, malaria, etc.)

- Coach CHW: experienced CHW identified to support and supervise about ten basic CHWs within the health area.

For better understanding, countries have been asked to select the two main categories of CHWs in place, as described below, that have been detailed, compared, and analyzed regarding the following aspects - status, means of recognition, remuneration and benefits, and the education level required and training provided, as well as the density and attrition rate of workers.

Category 1: being the most qualified CHW or the one with the more comprehensive package of services, and

Category 2: being the CHW with a smaller package of services or supervised by the first one.

Table 1- Designation of main community health workers in WCAR countries

COUNTRY Category 1 Category 2

BENIN Qualified Community Health Worker5 (Agent de santé communautaire qualifié)

Relay (Relai)

BURKINA FASO

Community-Based Health Worker (Agent de santé à base communautaire)

-

CAMEROON Skillful CHW (ASC qualifié)

Psycho-social worker (Travailleur psycho-social)

CAR Relay with comprehensive package (Relai)

Relay (Relai)

CHAD CHW (ASC) Relay (Relai)

CONGO Relay with comprehensive package (Relai)

Relay with standard package (Relai)

CÔTE D’IVOIRE

Coach CHW (Superviseur d’ASC)

Basic CHW, incl. peer educator (incl. ASC Formateur par les pairs)


5. Qualified CHWs are described in the strategic plan but not implemented yet


DRC Service provider relay (Relai)

Relay with promotional package (Relai)

GAMBIA, THE Community Health Nurse (CHN)

Village Health Worker (VHW) and Community Birth Companion (CBC)

GHANA Community Health Officer (CHO)

Community Health Volunteer (CHV)

GUINEA CHW (ASC) Relay (Relai)

GUINEA BISSAU

CHW (ASC) -

LIBERIA Community Health Assistant (CHA)

Community Health Volunteer (CHV)

MALI CHW (ASC) -

MAURITANIA CHW (ASC) Relay (Relai)

NIGER Relay with comprehensive package (Relai)

Relay with promotional and preventive package (Relai)

NIGERIA Community Health Extension Worker (CHEW)

Community Oriented Resource Person (CORP)

SENEGAL ACs,incl. CHWs, matrons, CHWs/matrons, and DSDOM(ASC, matrones, sage-femmes traditionnelles formées, DSDOM)

ACPP,incl. relays, bajenu gox, and traditional medicine practitioners (relai, bajenu gox, praticien de médecine traditionnelle)

SIERRA LEONE CHW -

TOGO CHW (ASC) Relay (Relai)

3.3. ASCs’ status and means of recognition

Recognition in the national Public Health code/lawOnly half of the countries recognized the CHWs in the Public health code/law, with 10/20 countries recognizing the first category of workers and 7/20 countries acknowledging the second.

For instance, The Gambia recognizes the first ones (CHNs) but do not recognizes VHWs and CBCs, whereas on the contrary DRC does not recognize the Service provider relay but do recognize the Relay with promotional package.

Types of contract ‘State volunteer’ type of contract is predominant for both categories (1st: 9/20, 2nd:7/20). The first category of CHWs are civil servants in four countries (The Gambia, Ghana, Guinea, and Nigeria), however, regarding the second category of workers, none of them is civil servant.

Figure 6- Distribution of community workers statuses in WCAR countries

4

0 02

34

97

3 32

0

4

6

Civil

serv

ant

State

cont

ract

or NGO

cont

ract

or State

volun

teer NGO

volun

teer

Comm

unity

volun

teer

Mun

icipa

lity/lo

cal/a

utho

rity

/ ASACO co

ntra

ctor

category 1 worker category 2 worker

Num

ber

of c

ount

ries



1st category: They are either NGOs contract workers or NGOs volunteers in Cameroon, Congo, and Senegal, whereas they are state volunteers in Burkina Faso, Chad, Côte d’Ivoire, DRC, Liberia, Mauritania, and Sierra Leone. In Niger, they are either state or NGOs volunteers. In Benin, CHWs are municipal contract workers. CAR, Guinea Bissau, and Togo qualify their CHWs status as community volunteers. Finally, in Mali, CHWs have contractual relationships with community health organizations (ASACO) or local authorities. Besides, the contract assumes the form of a performance-based contract in Benin, Congo, and Liberia.

Only a few countries specified who are the stakeholders signing the contract, namely: (i) representative of the health district in Sierra Leone and Liberia; (ii) the head of village, head of administrative district (arrondissement), and mayor of municipality in Benin; (iii) community health organizations (ASACO), municipalities, and the head of health district in Mali; and finally (iv) NGOs and civil society organizations (CSOs) in Cameroon and Congo.

2nd category: CHWs from the 2nd category sign a contract in only five countries. The psycho-social workers in Cameroon and Relays in Guinea are state contract workers. Nigeria’s CORPs are NGOs contract workers, whereas the Congo’s Relays with standard package, CAR’s Relays and Senegal’s ACPPs are both NGOs contract workers and volunteers. Finally, all others are volunteers - Basic CHWs in Côte d’Ivoire, VHWs and CBCs in The Gambia, CHVs in Liberia are state volunteers, while Promotional and preventive relays in Niger, Promotional relays in DRC, and Relays in Chad and Mauritania are both state and NGOs volunteers. Benin, Ghana, and Togo designate them as community volunteers (named by the community they work in). Relays in Benin and Congo get a performance-based contract.

Duration of contractThe duration of the contract is rarely stipulated. An employment contract of indefinite duration is signed by 1st category of CHWs in 4/20 countries (The Gambia, Ghana, Mali, and Nigeria) and 3/20 countries offer a contract of limited duration (Benin, Cameroon, and Liberia).

In the 2nd category, Nigeria’s CORPs are the only ones to get an employment contract of indefinite duration. Psycho-social workers in Cameroon and Relays in CAR get a contract of definite duration, respectively signed by the National AIDS Committee and the NGO involved.

Time allocation to the function of CHWs

The time allocation to the function of CHWs is usually categorized as (i) indeterminate, (ii) according to the needs of the community, (iii) part-time (less than 25 hours per week) and (iv) full-time (30 hours per week or more or from 20 to 31 days per month). While information on time allocation to the function is available for most countries (19/20) for the 1st category of CHWs, time allocation is mostly unclear for the 2nd category (5/20).

Table 2- Time allocation for activities of both CHWs categories in WCAR

Time allocation 1st category of CHWs

2nd category of CHWs

Indeterminate Burkina Faso, Côte d’Ivoire, DRC

Part-time (less than 25 hours per week)

CAR, The Gambia, Guinea Bissau, Liberia, Mali, Mauritania, Sierra Leone, Senegal and Togo

Nigeria and Togo

Full-time (30 hours per week or more or from 20 to 31 days per month)

Congo, Ghana, Guinea, Mali, and Nigeria

Cameroon and Guinea

According to the needs of the community

Benin, Cameroon Benin



National registrationBoth categories of CHWs benefit from registration through census/mapping, in 18/20 countries for the 1st category (i.e. except for Benin and Chad) and 16/20 for the 2nd (i.e. except for Benin, Cameroon, chad and Ghana).

The 1st category of CHWs benefit from registration at:- national level in eight countries, - regional in six, and - local in 14 (including health area and community

levels)

Regarding the 2nd category of workers, census/mapping is in place in 16 countries, and registration is completed at:- national level in only two countries, - regional level in four, and - local level in 12 (including health area,

neighborhood/block, village, or community levels).

Signs of recognition1st category of CHWs: they are provided with identification marks such as jackets, tee-shirts, or caps (in half of the countries), such as identification card or badge (in seven countries), or an attestation (in seven countries). Côte d’Ivoire, Liberia, Senegal (only for DSDOM), and Sierra Leone provide all of these recognition marks.

2nd category of CHWs: workers are provided with jackets, tee-shirts, or caps in seven countries - including Cameroun (psycho-social workers), CAR, Chad, Congo, Togo (Relays), Côte d’Ivoire (Basic CHWs), and Liberia (CHVs); with identification card or badge in three countries - Cameroon, Chad and Côte d’Ivoire; or with an attestation in two countries - Congo and Côte d’Ivoire. Only Côte d’Ivoire provides all of these recognition marks to Basic CHWs.

3.4. RemunerationFigure 7 gives the number of countries in the WCAR implementing the different modes of remuneration of CHWs

Figure 7- Number of WCAR countries implementing the different modes of remuneration for each category of workers

7

14

5

2

10

3

7 7

1

10

Mon

thly

salar

y

Mon

thly

mot

ivatio

n

Perfo

rman

ce-b

ased

Profit

from

prod

ucts

sale

Spora

dic

per d

iem


Monthly salary First category of CHWs earn a monthly salary in Benin, The Gambia, Ghana, Guinea, Liberia, Mali, and Nigeria, equivalent to 50 US$ in Nigeria, 70 US$ in Mali and Liberia, and 167 US$ in Guinea. However, only three types of CHWs within the 2nd category get a monthly salary: Cameroon’s psycho-social workers, Nigeria’s CORPs, and CAR’s Relays (the latter also get sporadic per diem), respectively equivalent to 126 US$, 42 US$, and ranging from 18 to 90 US$.

Monthly motivationIn 14 countries, CHWs are paid through a monthly motivation (most of the time after validation of report), equivalent to 18 US$ (10,000 FCFA) or less in Niger, Guinea Bissau, CAR, and DRC; and ranging from 36 to 54 US$ (20,000 to 30,000 FCFA) in Burkina Faso, Cameroon, Chad, and Côte d’Ivoire. The amount of the motivation is unspecified for Sierra Leone (equivalent to transport and other expenses based on reporting of work) and Togo.

In Nigeria, the monthly salary (cat 1) is complemented with a 28 US$ monthly motivation (coming from the Drug Revolving Fund).

Seven countries state that the 2nd category workers get a monthly motivation, but it seems



to be a fix amount in only two of them (about 36 US$ in Côte d’Ivoire and 167 US$ in Guinea but as these two types of workers have not been recruited yet, these incentives probably are not in place yet).

Performance-based remunerationPerformance-based remuneration is in place in Cameroon, Congo, Côte d’Ivoire, and Senegal for the first category. In Benin, the monthly salary (cat 1) is completed by a quarterly bonus based on performance, and by a motivation in The Gambia, Liberia, and Mali.

Concerning the 2nd category, performance-based remuneration is in place in six countries - Benin, Congo, Côte d’Ivoire, DRC, Liberia, and Senegal - but mostly as part of partners driven programs. Chad also reports a specific remuneration through the Guinea worm national program that offers 45 US$ (25,000 FCFA) for each case detected and referred to the health center.

Profit from products saleCHWs gets a remuneration based on the margin made from the sale of drugs in Mauritania, and the sale of Rapid Diagnostic Tests (RDTs) in Cameroon.

Per-diemIn addition to these fixed remunerations, CHWs from both categories receive sporadic per diem when meetings, trainings, or other extra-activities in Côte d’Ivoire, CAR, DRC, The Gambia, Mauritania, Niger, Senegal, and Togo. Other countries provide only one category with per diem - Burkina Faso and Cameroon for the 1st category, and Benin and Chad for the 2nd category. These daily amounts vary between 5 to 9 US$ in Burkina Faso, Côte d’Ivoire, Niger, and DRC, and reaches 18 to 27 US$ in CAR. The five other countries did not mention the amount of per diem.

3.5. Retention strategy Except for Cameroon, Chad, Congo, and Mauritania, all other countries (80%) declare having developed a retention strategy for the 1st category of CHWs and 69% of countries have developed a retention strategy for this 2nd

category of workers.

BenefitsAmong the most common advantages offered to 1st category of workers are benefits received from the community (occurring in 56% of countries) and exemption from fees for healthcare (in 50% of countries), whereas involvement of CHWs in peer training happens in 38% of countries. Also, Côte d’Ivoire mentions other advantages such as exchange and experience sharing trips at national and sub-regional level. Honorific awards are also given to CHWs in 20% of countries.

In the 2nd category, CHWs should receive benefits from the community in half of the countries. In addition, we can mention: involvement in peer training in Ghana, Niger, Nigeria, and Senegal; exemption from fees for healthcare in Benin, CAR, Côte d’Ivoire, DRC, and Togo; honorific awards in Côte d’Ivoire, Ghana, Guinea, and Senegal; and finally. Chad, where no retention strategy is in place, mentions that partners sometimes give a bike to Relays or ask the community to find the best way to motivate the community workers, whether in cash or in kind.

Career ladderCareer ladder is rarely offered to CHWs, with only 25% of countries for the 1st category and in only two countries (Côte d’Ivoire and Guinea) for the 2nd category.



3.6. Educational background and trainingSelection criteria1st category: no educational level is required in Sierra Leone to become a CHW. Ability to read and calculate is required in Cameroon, CAR, Chad, DRC, Liberia, Niger, Senegal, and Togo. Having achieved primary-school level is mandatory in Burkina Faso, Guinea Bissau, Mali, Mauritania, and Nigeria. Finally, Benin, Congo, Côte d’Ivoire, The Gambia, Ghana, and Guinea require that CHWs have secondary education level.

2nd category: The Gambia, Liberia, and Niger do not require any education level to be respectively VHW and CBC, CHV, and Promotional and preventive relay. In Benin, CAR, Mauritania, and Nigeria, Relays and CORPs must have a primary-school level. The most common requirement is ability to read and calculate, applicable in eight countries - Cameroon (psycho-social worker), Côte d’Ivoire (basic CHW), Chad (relay), DRC (promotional relay), Guinea (relay), Senegal (ACPP), and Togo (relay). Finally, in Congo, relays with standard package must have a secondary level. In Ghana, CHVs may either have primary or secondary level, or be able to read and calculate.

The following figure summarizes the educational level requirements by number of countries and category of workers.

Figure 8- Number of WCAR countries according to the educational level required, for each category of workers

1

8

56

3

9

5

2

None

Readin

g an

d

calcu

lation

Primar

y lev

el

Secon

dary

leve

l


Pre-service trainingAll countries provide pre-service training to CHWs from the 1st category, which duration ranges from 6-7 days (CAR, Congo, and DRC) to two years in Ghana and Guinea (but that includes the initial education required to be able to apply to be a CHW). The duration of the training is between 6 and 15 days in Burkina Faso, Cameroun, CAR, Congo, Côte d’Ivoire (6 days of theory and 6 days of practice), DRC, and Togo; and between 21 and 26 days in Guinea Bissau, Mali, Mauritania, and Niger. The training lasts more than a month in Liberia, Senegal, and Sierra Leone, (respectively 48 days - 38 days theory and 10 days practice, 40 to 55 days and 3 months). In Nigeria, CHOs are trained for two years in basic nursing, and then receive a two-week top-up training in community entry and mobilization, whereas CHEWs receive a 24-week training (divided between 6 weeks in classroom and 18 weeks of field practicum). In Benin, CHWs that necessarily graduated a nursing and obstetric care degree training, get a 12-week pre-service training that includes 4 weeks of theory and 8 weeks of practice. Chad states that duration of training varies according to thematic.

Figure 9- Distribution of number of WCAR countries according to training duration ranges for category 1 workers

5

2

7

3

2

1

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day

s

> 1 m

onth

21-2

6 da

ys

Nursin

g tra

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man

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ry2

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Variab

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All workers from the 2nd category, except for CHVs in Liberia, receive a pre-service training, of which duration is between one to three days (Ghana) and 40 to 55 days (Senegal). In most of countries (eight of them), duration is between 5 and 11 days. Actually, in Togo, Senegal, DRC, Côte d’Ivoire, and CAR, the two types of workers get the same duration training, but differences are observed in the content of the training. As a matter of fact, in Senegal, it is specified that a community health worker is often ACPP and ACs at the same time.

Continuous trainingCHWs from 1st category receive in-service/refresher training in more than half of countries, which happens once a month in Guinea Bissau (in addition to the formative supervision all along the month), and in CAR (which becomes quarterly after 5-6 months). The refresher training takes place twice a year in Ghana, once a year in Cameroon, Côte d’Ivoire, Guinea and Senegal, and every two years in Burkina Faso, Sierra Leone, Togo, and Niger (specifically in case of evolution of training modules). In The Gambia, refresher occurs every 3 weeks, 21 weeks or once a year, highly depending on resources.

Figure 10- Distribution of refresher training periodicity for category 1 workers by number of WCAR countries

1

4

2

4

1

1/m

onth

1/ye

ar

2/ye

ar

Every

2 ye

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Variab

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For the 2nd category of CHWs, more than half of countries (9/16) provide refresher training to the second category of workers; however, Senegal and Niger specify that it does not take place in a systematic way (respectively “as needed and according to resources” and “in case of revision of the training modules”). When refresher training occurs, the frequency is pretty much the same for the two categories of workers, except for Ghana where it happens twice a year for CHOs and every two years for CHVs, and for Chad where it seems that there is no refresher for CHWs while relays get in-service training at least three times a year (mainly when they are NGOs volunteers).

3.7. DensityThe number of 1st category CHWs registered when census is in place ranges from 106 CHNs in The Gambia to 20,000 CHOs in Ghana. The number of 2nd level workers registered is a lot more important than the workers of the first category, ranging from 810 VHWs and CBCs in The Gambia to 340,000 Promotional relays in DRC; that number passes beyond 10,000 in Benin, Côte d’Ivoire, and Senegal.

Density of CHWs per populationDensity of CHWs is variable for both categories and among countries.

CHWs, from the 1st category, are allocated per villages in Benin, Burkina Faso, DRC, The Gambia, and Mauritania; the ratio is one CHW per village in Benin, two CHWs per village (with additional CHWs if more than 2,000 inhabitants and with a maximum of four per village) in Burkina Faso, one CHW in each village located more than 5 km from a health facility with more than 500 inhabitants in Mauritania and DRC, and one CHW per six PHC villages in The Gambia. Repartition is made upon households in Liberia, Sierra Leone, Chad, and CAR, being respectively 1 CHW/40 to 60 households, 1/100, 1/50 to 100, and 2/250. The number of CHWs is determined



by the number of people in Cameroon (1/1,000 in rural areas and 1/2,500 in urban areas), Congo (1/150), Ghana (1/3,000), Guinea (1/6,500), Guinea Bissau (1/350), Mali (1/700 to 800), and Niger (1/500). Finally, in Côte d’Ivoire, one Coach CHW supervises 10 Basic CHWs. The repartition mentioned is deemed to be pretty much effective in most of countries, except for Congo (1/300 people when it should be 1/150 people) and Chad; in Benin and Guinea where the type of CHW mentioned is not implemented yet, the effective density is still unknown.

Regarding the 2nd category, in Congo, Côte d’Ivoire, The Gambia, Ghana, Guinea, and Niger, the density varies between one community worker per 250 people to 1/650. In Benin, CAR, DRC, Mauritania, and Senegal, density is expressed in number of relays per household and should be between 1/10 (Senegal) and 2/250 (CAR). There is no recommended density in Chad and Nigeria. This density seems to be more or less effective in DRC, The Gambia, Ghana, Guinea, Mauritania, and Niger.

Attrition rateAttrition rate of 1st category CHWs is only known in five countries and is about 1 to 5 % in Togo, Sierra Leone, and Mali, while it reaches 15% in Guinea Bissau and Cameroon.

Only two countries know the attrition rate for workers of the 2nd category, which is 1% in Togo (the same as the 1st category CHWs attrition rate) and ranges from 13 to 15% in Benin (which was unknown for the 1st category CHWs).



4. GENDER RESPONSIVENESS

4.1. Policy review20% of countries (Burkina Faso, Chad, Congo, Niger) call for a two-person team, one woman and one man, whereas 25% (CAR, Côte d’Ivoire, Liberia, Mauritania, Sierra Leone) state that preference should be given to women. Among them, CAR stipulates that “mother women” should be preferred.

Regarding the gender equality within the committees, Mauritania requires that at least a member of Health committees be a woman, and Ghana tends towards gender-balanced Community Health Management Committees (CHMCs).

However, it is important to notice that 40% of countries do not broach the gender dimensions in the policy documents, and 2 countries briefly state, respectively, that “the approach is taken into account through the recruitment of human resources” (Benin), and that “a gender imbalance is to be noticed among CHWs, with 82% of men and 18% of women” (Togo).

Given these findings, policies are obviously insufficiently gender-responsive.

Figure 11- WCAR countries where are found gender-balanced pairs of CHWs or predominance of women

women preferred

team 1 woman / 1 man

4.2. Gender balance in recruitmentThe CHWs sex ratio is known in about 13 countries and is predominantly male in most of them, ranging from 17% of female in Liberia - nevertheless highly variable depending on the regions (25% in Maryland while 9% in Sinoe county) - to 40% in Benin. However, in The Gambia, out of the 810 CHWs (which include both VHWs and Community Birth Companions (CBCs)), 55% are females which are mainly CBCs. Neither in Mauritania, nor Niger the exact sex-ratio is known but they both state that the ratio is unbalanced, respectively predominantly female and male. Both Congo and Chad report that the ratio is about 1 (the second one mentioning that there are one female and one male CHWs in each village). Ultimately, only Mauritania have predominantly female CHWs (and also The Gambia but only due the proportion of CBCs) and Congo and Chad report parity; all others have male predominance.

4.3. Gender-specific advantages/disadvantages

According to the respondents, the main factors influencing the unbalanced sex ratio6 are: - sociocultural constraints, including husband’s

decision-making authority, - women’s heavy workload at home and their

lower level of education.

Benefits to have CHWs women that have been mentioned by respondents are most often related to the fact that:- women are more comfortable with the main

themes of community health (pregnancy, childbirth, breastfeeding, childhood illnesses, family planning, etc.),

- they are more stable in the community than their men counterparts, that more often tend to migrate to towns looking for lucrative jobs which, for that matter, impacts attrition rate of CHWs in the programs.

However, Nigeria, despite stating that women CHWs are deemed to be more able to address

RESULTSGender Responsiveness

6. Same justifications that come up in almost all answers


women and children diseases, specifies that men CHWs are preferred in urban settings. Also, many countries highlight that in Muslim communities it is preferable that male CHWs attend male patients and female CHWs, the female ones.

4.4. Gender-responsiveness of policy documents

13 countries, out of 20, state that the community health policy is gender-responsive; most of them justifying it by the fact that female applications are highly encouraged. Also, DRC specifies that, in Kinshasa, community volunteers’ (RECOs) spouses are now involved in care activities. Benin, Cameroon, The Gambia, Ghana, Mauritania, and Senegal admit that it is not gender-responsive, and Nigeria did not find the question applicable since there is no community health policy in force.

However, in the in-depth surveys only three countries (Benin, Ghana, and Guinea) have conducted a gender analysis; confirming that policy documents are not gender-responsive.

Box 3: Example of Mauritania as a regional exception for sex-ratio

Mauritania: a regional exception for sex-ratio

Whereas the majority of CHWs globally are women, Mauritania is the only country in the West and Central Africa region where CHWs are predominantly women - although the exact sex-ratio of CHWs is unknown there. According to the national respondents to the survey, an explanation of such a fact would be based on the one hand on the more expected stability of women in villages, and on the other hand on a potential users’ preference, as women find it easier to talk to other women about maternal and child health, and especially pregnancy and delivery questions.

However, the predominance of female CHWs may reflect both empowerment of women and their contribution to address health issues in the community, but also the reinforcement of gender inequalities, given that CHWs are often unpaid or underpaid and that this may highlight the predominance of women in lower level positions. A multi-country research to be conducted by UNICEF WCARO and partner will allow to further explore this aspect in the region, including Mauritania.




5. PACKAGE OF SERVICES

5.1. Definition of package of services in

policy documentsThe package of services defined in the policy documents is highly variable among countries. However, there are common activities that are found in all countries and include promotion, prevention and treatment.

PROMOTION:o Key Family Practices (65% of countries)o Birth registration (40%)o Infant and Young Child Feeding (35%)o Wash (55%)

PREVENTION: o Defaulters tracking and follow up (especially

for ANC, PNC, Immunization, P/eMTCT, TB, etc.) (45%)

o LLITNs delivery and follow up (35%)o Vitamin A and iron supplementation (30%)o Deworming treatment (albendazole/

mebendazole) (25%)o Family Planning (50%)

MANAGEMENT OF CHILDHOOD ILLNESSES: o Acute Respiratory Infection (ARI)/pneumonia,

with amoxicillin treatment (75%)o Uncomplicated malaria - diagnosis (RDT) and

treatment (ACT) (75%)o Diarrhea, with ORS/Zn treatment (75%)o Sometimes, management of acute

malnutrition (15%)

Added to these essential activities, - Community surveillance (50% of countries)- Rehabilitation (25% of countries) - e.g.:

o Community-based rehabilitation of people with disabilities in Togo

o Follow-up of complications of lymphatic filariasis in Senegal

- Other: Prevention of gender-based violence, female genital mutilation, and child marriage

Based on this policy review and approaching community health systems through a life cycle lens, we have divided the package of services into seven components for an in-depth analysis: i) antenatal and newborn (up to 28 days) care (promotion/prevention), ii) childhood illnesses (under five)/iCCM (promotion, prevention, curative care), iii) adolescents, iv) family planning, v) HIV, vi) tuberculosis, and vii) community-based surveillance.

Figure 12- Number of WCAR countries implementing each component of the package of services

20 1920 19

1216

20

Anten

atal a

nd

new bo

rn ca

re

Adoles

cent

hea

lth

Childh

ood

illnes

ses TBHIV

Fam

ily p

lannin

g

CB surv

eillan

ce

For each of the components, countries were asked to select the specific services that are effectively implemented and the scope of their implementation (fully implemented7 or partially implemented8) and at what scale (number of health districts).

5.2. Antenatal and newborn careScope of implementationThe package of services for antenatal and newborn care is implemented in all countries. The respective antenatal and newborn care packages of services of Burkina Faso, The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, Niger, Nigeria, Senegal, and Sierra Leone are fully implemented in all health districts/areas/Local Government Areas. The package is fully implemented in some health districts in Cameroon, Liberia, and Mali (respectively in 80/189, 79/90, and 47/65).

RESULTSPackage of services

7. Fully implemented: all activities of the package of services are implemented in all communities in the district8. Partially implemented: only a few activities of the package are implemented, or all activities are implemented but only in a few communities in the district


Finally, the package is partially implemented in all health districts in Benin and Côte d’Ivoire, and in some health districts in CAR, Congo and Liberia (respectively 9/35, 22/53 and 11/90).

Figure 13- Geographic coverage of ANC full implementation in WCAR countries

20 1920 19

12

162020 1920 19

12

16

Guinea

Guinea

Biss

au

Ghana

Gambia

, The

Camer

oon

Burkin

aFa

so

Seneg

al

Niger

Liber

iaM

ali

Mau

ritan

ia

Nigeria

Sierra

Leo

ne

Figure 14- Geographic coverage of ANC partial implementation in WCAR countries

2641

100 100

12

Benin

Congo

CAR

Côte

d’Ivo

ire

Liber

ia

Missing data for Chad, DRC, and Togo

PromotionPromotion and reference for the four-recommended antenatal care visits (ANC), promotion of long-lasting insecticide-treated nets (LLITNs) use, promotion of exclusive and early breastfeeding, and promotion of immunization are implemented in all 20 countries. For other promotional activities - promotion of iron/folic acid, of prevention of HIV mother-to-child transmission (PMTCT), of delivery in presence of a skilled birth attendant, of skin to skin contact, of Kangaroo Mother Care (KMC) method at

community level, of post-partum contraception, or of birth registration - 70 to 90% of countries have them included in their antenatal and newborn care promotional package. However, only six countries (Chad, The Gambia, Mauritania, Niger, Senegal, and Sierra Leone) have CHWs promoting early childhood development (ECD) at community level.

Figure 15- Number of WCA countries where CHWs provide the different promotional ANC services

1518

20

14

6

16

2018

20

1718

20

Delive

ryw

/ skil

led b

irth

atte

ndan

t

Skin to

skin

cont

act

PMTC

T/EM

TCT

LLIT

N use

Iron

/ Foli

c acid

4 ANC

visits

Early

child

hood

dev

elopm

ent

Birth

regis

tratio

n

Kanga

roo

mot

her c

are

Exclus

ive e

arly

brea

stfe

eding

Post-p

artu

m co

ntra

cept

ion

Imm

uniza

tion

Num

ber

of c

ount

ries

PreventionHome visits after delivery (24 hours, 72 hours, and 7 days) and search for danger signs in mother and newborn as well as referral, are respectively implemented in 17 and 19 countries. Other preventive activities are all implemented in less than 60% of countries - support during labor in presence of a skilled birth attendant, provision of misoprostol to prevent post-partum hemorrhage, cord care (through drying or using chlorhexidine), newborn weight or temperature control, KMC initiation or support.



Figure 16- Number of WCA countries where CHWs provide the different prevention ANC services

Num

ber

of c

ount

ries

91111

19

6

17

10

7

12

8

Cord

care

-chlor

hexid

ine

Newbo

rn w

eight

cont

rol

Cord

care

-dry

Home

visits

afte

r deli

very

Miso

pros

tol/p

reve

ntion

pp he

mor

rage

Suppo

rt

durin

g lab

or

Searc

h fo

r dan

ger s

igns

and

refe

rral

Newbo

rn te

mpe

ratu

re co

ntro

l

KMC-in

itiatio

n

KMC-m

ainte

nanc

e

Other antenatal and newborn care services have been mentioned as being implemented in some countries, such as management of malaria non-complicated cases of pregnant women after the first trimester (with RDT and ACT) in Mali, and malaria intermittent preventive treatment in pregnancy (IPTp) in Burkina Faso (in 3 health districts out of 70).

For the record, in Burkina Faso, although the overall package of antenatal and newborn care activities is fully implemented, home visits after delivery are partially implemented with CHWs carry them out in only 28 health districts out of 70.

5.3. Childhood illnessesScope of implementationThe nationally defined package of services for childhood illnesses/iCCM is fully implemented in all health districts/areas in The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, Nigeria, Senegal, and Sierra Leone, and fully implemented in some health districts/areas in Cameroon, Mali, and Togo (80/189, 47/65, and 22/41). The package is partially implemented in all districts in Benin and Côte d’Ivoire, and in some districts in CAR,

Liberia, and Niger (11/35, 11/90, and 19/72). In Congo, the promotional and preventive iCCM package of services is partially implemented in 22/53 districts, whereas the curative one is partially implemented in only 3/53 districts.

Figure 17- Geographic coverage of iCCM full implementation in WCAR countries

100

42

7254

100 100100 100100 10010010088

Guinea

Guinea

Biss

au

Ghana

Gambia

, The

Camer

oon

Burkin

a

Faso

Sierra

Leo

neNige

r

Liber

iaM

ali

Mau

ritan

ia

Seneg

al

Togo

Figure 18- Geographic coverage of iCCM partial implementation in WCAR countries

31

100 100

6

41

1226

Benin

Congo

pro

m &

pre

vCAR

Liber

ia

Côte

d’Ivo

ire

Congo

cura

tive

care

Niger

Missing data for Chad and DRC

PromotionIn all countries, CHWs carry out promotional activities regarding LLITNs use and nutritional education, including exclusive breastfeeding until six months and breastfeeding until two. Other promotional activities regarding children immunization, control of vaccination record, and nutritional education focusing on young child feeding, are implemented in 90 to 95% of countries. Then again, ECD promotion is effective in a lower proportion of countries (60%).



Figure 19- Different promotional childhood illnesses services provided by CHWs in WCAR countries

Num

ber

of c

ount

ries

1819 1920 20 20

12

lmm

uniza

tion

Nutrit

ional

educ

ation

Vacc

inatio

n rec

ord c

ontro

l

LLIT

N use

Young

child

feed

ing

Excl. b

reas

tfeed

ing u

ntil

6 m

ths a

nd b

reas

teed

ing u

nt2 ECD

Also, Mali mentioned that the promotion of enrollment of girls and boys in school is part of the promotional activities.

PreventionSome preventive activities for childhood illnesses are implemented in almost all countries (95%), namely provision of vitamin A and deworming treatment (albendazole/mebendazole), mid-upper arm circumference measure (MUAC) screening and referral, and search for danger signs and referral of. Although CHWs provide vitamin A and deworming treatment in 19 countries out of 20, it is occurring mostly during campaigns in 18 countries but through routine activities in only seven of them. Other activities are implemented to a lesser extend: growth control (65%), distribution of micronutrients powder (MNP) (45%), ECD (including active participation of CHW through games, songs, massages, etc.) (25%) and child protection (50%).

Figure 20- Different prevention childhood illnesses services provided by CHWs in WCAR countries

Num

ber

of c

ount

ries

13

5

9

10

18

7

19 1919

Grow

th co

ntro

l

MUAC sc

reen

ing/re

ferra

l

VitA-D

ep-ro

utine

VitA-D

ep-ca

mpa

igns

VitA-A

lbend

azole

-

-Meb

enda

zole

Child

prot

ectio

n

Micr

oNut

rient

s pow

der

Searc

h fo

r dan

ger s

igns

and

refe

rral

ECD

Burkina Faso added in this prevention component the services provided by CHWs during campaigns for seasonal malaria chemo-prevention (SCP). This may be true in other countries, but it was not specified during the survey.

Curative careAll countries implement management of the three main children killer diseases - pneumonia, malaria, and diarrhea - at community level, which is better known as iCCM. As a reminder, this includes management of fever with paracetamol, management of pneumonia with amoxicillin DT, management of diarrhea with oral rehydration salts (ORS) and Zinc, and management of malaria, diagnosed with RDT and treated with ACT.

Also, seven countries - Chad, The Gambia, Ghana, Guinea, Mali, Nigeria, and Togo - stated that severe acute malnutrition (SAM) is managed at community level, with amoxicillin and ready-to-use therapeutic food (RUTF).

As activities of interest included in this curative package, Côte d’Ivoire also added management of moderate acute malnutrition (MAM) with ready-to-use food.



Figure 21- Different curative childhood illnesses services provided by CHWs in WCAR countries

20 20 20 20

7

Feve

r

Pneum

onia

Diarrh

ea

Mala

ria

Sever

e Acu

te

Maln

utrit

ion

Num

ber

of c

ount

ries

5.4. Adolescent healthScope of implementationServices to adolescents at community level are provided in only 12 countries - Cameroon, Chad, Congo, Côte d’Ivoire, DRC, The Gambia, Guinea, Liberia, Mali, Nigeria, Senegal, Sierra Leone. The package of services is fully implemented in all districts in five of them: The Gambia, Guinea, Nigeria, Senegal, and Sierra Leone. The package is partially implemented in all districts in Côte d’Ivoire, and in some districts in Cameroon and Congo (80/189 and 18/53). In Liberia, package of services is fully implemented in 79 districts (88%) and partially in 11 (12%). DRC and Chad did not provide the coverage figures of services to adolescents.

Figure 22- Geographic coverage of adolescent services full implementation in WCAR countries

72

100100 10010088

Camer

oon

Guinea

Seneg

alM

ali

Liber

ia

Sierra

Leo

ne

Gambia

, The

42

Figure 23- Geographic coverage of partial implementation of adolescent health services in WCAR countries

34

100

12

Congo

Côte

d’Ivo

ire

Liber

ia

Services offered to adolescentsOnly a few countries implement activities targeting adolescents at community level. Between 25 and 45% of countries implement an adolescent package of services with focus on: prevention of teenage pregnancies, menstrual hygiene, prevention of child marriage, iron/folic acid, and nutritional education. Human papilloma virus (HPV) vaccination is carried out at community level in only three countries (15%), including The Gambia that specifies that, although the other adolescent activities of the package are fully implemented in all districts, HPV vaccine is provided at community level in only one region. On the other hand, HIV prevention towards adolescents is quite widespread since 55% of countries include it in the adolescent package of services. As other services targeting adolescents that should be mentioned here, Mali cited management of malaria cases with RDT and ACT, and prevention of Female Genital Mutilation (FGM).



Figure 24- Services provided to adolescent by CHWs in WCAR countries

9

5 5 5

11

6

3

Preve

ntion

teen

age p

regn

ancie

s

Preve

ntion

child

mar

riage

Men

stru

al hy

giene

Nutrit

ional

educ

ation

Iron/

Folie

acid

HPV vacc

ine

HIV p

reve

ntion

Num

ber

of c

ount

ries

5.5. Family planningScope of implementationFamily planning services are provided at community level in all countries, except for Niger. The package of services is fully implemented in all districts in Burkina Faso, The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, Nigeria, Senegal, and Sierra Leone; partially implemented in all districts in Côte d’Ivoire, and in a few districts in Benin, Cameroon, Congo, Togo (5/34, 80/189, 22/53, 5/41). Finally, in Liberia, family planning package of services is fully implemented in 79 districts and partially in 11.

Figure 25- Geographic coverage of full implementation of family planning services in WCAR countries

100

72

100100 100 100100 100100100

Guinea

Guinea

Biss

au

Ghana

Burkin

a

Faso

Sierra

Leo

ne

Nigeria

Mali

Mau

ritan

ia

Seneg

al

Gambia

, The

Figure 26- Geographic coverage of partial implementation of family planning services in WCAR countries

42 42

100

15 12 12

Benin

Congo

Camer

oon

Liber

ia

Côte

d’Ivo

ireTo

go

Family planning servicesAll countries that implement a family planning package of services at community level (all 20 countries except for Niger), have included promotional activities. All of them, except for Mauritania, also include counseling and referral. On the other hand, among the countries that offer family planning services at community level, the proportion of them that include provision of contraception is highly variable depending on the contraceptive method: 84% of countries have CHWs providing condoms, 74% for pill (47% as initial offer and 79% as refill), and 42% for injectable (32% as initial offer and 37% as continuation). DRC also mentioned the provision of cycle string at community level.

Figure 27- Family planning services provided by CHWs in WCAR countries

14 151618

96

8 7

19

Provis

ion p

ill

Pill-ini

tial o

ffer

Provis

ion co

ndom

s

Couns

eling

/refe

rral

Prom

otion

Injec

table

-main

tena

nce

Provis

ion in

jecta

ble

Pill-re

fill

Injec

table

-initia

l offe

r

Num

ber

of c

ount

ries



For the record, in Burkina Faso, whereas other family planning activities are fully implemented (except for pill initial offer that is not part of the family planning package at community level), provision of injectable at community level is only implemented in two regions out of 70 (and only for continuation).

5.6. HIVScope of implementationHIV services are provided at community level in all countries, except for Niger. The national package of services is fully implemented in all health districts in Burkina Faso, The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, Nigeria, and Sierra Leone; it is partially implemented in all districts in Benin, Côte d’Ivoire and Senegal; and partially implemented in some districts in Cameroon and Congo (80/189 and 18/53). In Liberia, like the other components of the package of services, HIV is fully implemented in 79 districts and partially in 11. Figure 28- Geographic coverage of full implementation of HIV services in WCAR countries

100

72

100100 100 10088

100100100

Guinea

Guinea

Biss

au

Ghana

Burkin

a

Faso

Sierra

Leo

ne

Nigeria

Mali

Liber

ia

Mau

ritan

ia

Gambia

, The

Figure 29- Geographic coverage of partial implementation of HIV services in WCAR countries

4234

100 100100

12

Benin

Congo

Camer

oon

Liber

ia

Côte

d’Ivo

ire

Seneg

al

HIV servicesAmong the 19 countries out of 20 that offer HIV services at community level and in addition to PMTCT services described in the ANC section, 17 of them (89%) include education and prevention activities, 11 of them (58%) counseling for treatment adherence, and 12 (63%) awareness of stigma and discriminations.

Figure 30- HIV services provided by CHWs in WCAR countries

Num

ber

of c

ount

ries

17

1112

Educa

tion/

prev

entio

n

Couns

eling

trea

tmen

t

adhe

renc

e

Awar

enes

s

stigm

a/disc

rimina

tion



5.7. TuberculosisScope of implementationThe package of tuberculosis (TB) services is fully implemented in all health districts in seven countries - Burkina Faso, The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, and Senegal - and partially implemented in all districts in Benin and in some in Nigeria. In Liberia, some districts are subject of full implementation (79/90) and some other of partial implementation (11/90).

Figure 31- Geographic coverage of full implementation of tuberculosis services in WCAR countries

100

42

100 100 10010088

100100100

Guinea

Guinea

Biss

au

Ghana

Gambia

, The

Camer

oon

Burkin

a

Faso

Sierra

Leo

ne

Seneg

al

Liber

ia

Mau

ritan

ia

Figure 32- Geographic coverage of partial implementation of tuberculosis services in WCAR countries

100

12

Benin

Liber

ia

Tuberculosis servicesOut of the 16 countries implementing a TB package of services at community level, 14 of them (88%) include education of communities.

CHWs carry out detection and orientation of suspect cases in 15 countries (94%), whereas search and orientation of contacts of positive cases is only occurring in 12 countries (75%). Respectively 10 and 11 countries, out of 16, have CHWs carrying out home visits and follow-up of control appointments. Finally, Directly Observed Treatment (DOT) at community level is implemented in nine countries (Chad, Côte d’Ivoire, The Gambia, Guinea, Guinea Bissau, Liberia, Nigeria, Senegal, and Togo).

Figure 33- TB services provided by CHWs in WCAR countries

Num

ber

of c

ount

ries

10

15

1211

14

9

Educa

tion

Detec

tion/

orien

tatio

n

susp

ect c

ases

Home

visits

DOT

Searc

h/or

ienta

tion

cont

acts

Follo

w u

p of

appo

intm

ents

5.8. Community-based surveillanceScope of implementationCommunity-based surveillance takes place in all countries. The package of community-based surveillance is fully implemented in all health districts in Burkina Faso, The Gambia, Ghana, Guinea, Guinea Bissau, Mauritania, and Sierra Leone, partially implemented in all districts in Benin and Côte d’Ivoire, and in some of Congo, Niger, Nigeria, and Senegal. Like all other components of the CHW package of services, in Liberia, most of districts (79/90) are subject of full implementation and some others (11/90) of partial implementation.



Figure 34- Geographic coverage of full implementation of community-based surveillance

100

42

100 100 10010088

100100

Guinea

Guinea

Biss

au

Ghana

Gambia

, The

Camer

oon

Burkin

a

Faso

Sierra

Leo

ne

Liber

ia

Mau

ritan

ia

Figure 35- Geographic coverage of partial implementation of community-based surveillance

42

12

100

22

100

26

Benin

Congo

Niger

Liber

ia

Côte

d’Ivo

ire

Seneg

al

Community-based surveillance interventionsMore than 75% of countries have implemented community-based surveillance for cholera, measles, polio, maternal and neonatal deaths, mid-upper arm circumference measure (MUAC) screening and reporting of any suspicious case, unusual event or rumor circulating in the community. Between 50 and 75% of countries have included community-based surveillance for meningitis, hemorrhagic fevers (including Ebola Virus Disease), yellow fever, neonatal tetanus, and clustered deaths. 35% of countries also have implemented surveillance for flu and leprosy.

Figure 36- Diseases included in community-based surveillance activities

Diseases subject of surveillance by CHWs

Num

ber

of c

ount

ries

Hemor

ragic

feve

r inc

l.

Mea

sles

Men

ingitisFlu

Choler

a

MUAC sc

reen

ing

Mat

erna

l dea

ths

Guinea

wor

mPoli

o

Yellow

feve

r

Neona

tal t

etan

us

Lepr

osy

Neona

tal d

eath

s

Cluste

red

deat

hs

Suspic

ious c

ase/

even

t

19 16

7

12 13 15 16

11 11 14

7

18 17

12

16

In Mali, despite the statement that CHWs weekly report notifiable «suspect cases of disease», only surveillance of maternal, neonatal, and clustered deaths, as well as suspicious case, unusual event or rumor circulating in the community have been selected.

In Burkina Faso, surveillance of almost all diseases is fully implemented in all health districts, but reporting of clustered deaths and any suspicious case, unusual event or rumor circulating in the community only occurs in three regions out of 70.

Also, anthrax has been mentioned as subject of surveillance at community level in Guinea Bissau.



6. SUPPLY CHAIN MANAGEMENT

6.1. Supply plans15 countries out of 20 have developed a national procurement plan, including national Standard Operating Procedures. Among these ones, 13 plans include procurement of medicines needed for community cases management, 11 also include procurement of equipment needed at this level, and nine include supply of communication tools too. The nine countries whose plan encompasses these three areas are Chad, DRC, The Gambia, Ghana, Guinea, Niger, Senegal, Sierra Leone, and Togo.

Figure 37- Existence of procurement plans for components of the care services planned at community level in WCAR countries

Num

ber

of c

ount

ries

1513

119

Existe

nce

of p

rocu

rem

ent

plan

Plan in

clude

s

proc

urem

ent o

f

med

icine

s nee

ded

for C

CMPlan

inclu

des

proc

urem

ent o

f

equip

men

t nee

ded

Plan in

clude

s

supp

ly of

com

mun

icatio

n

tools

6.2. Integration into national supply system

Among the 15 countries that have such a supply plan, community procurement for medicines and equipment is integrated into the national supply system for 13 of them (not the case for

Benin and Togo). Also, Cameroon that has not developed a community level procurement plan, stipulates that community health procurement is integrated into national supply system anyhow. However, among all of them, nine admit that this system is not effective for the moment.

Quantification systems, procurement plan, inventory control, resupply logistics system and logistics management and information system (LMIS) are rarely part of the policy documents. Though, some policies reveal that national supply systems are not ready to support community supply yet, and therefore detail a parallel circuit, involving partners (e.g.: Niger, Nigeria, and Sierra Leone).

Among the identified challenges for community level procurement, we can highlight the following ones that have been frequently mentioned: frequent stock-outs, lack of community level consumption data, poor quantification or planning capacities, issues regarding initial dotation to CHWs/relays, donor-dependent procurement, limited resources, poor monitoring and supervision, weak distribution partly due to transportation difficulties and costs.

Some possible solutions to overcome these dysfunctions have also been identified, including: systematize micro-planning of drugs and other health products requirement at health center level, taking into account the needs of CHWs; build capacity in logistics management at health center and community levels and strengthen supervision; set up close monitoring of the usage of medicines at community level; ensure appropriate mechanism for tracking of suppliers and ensure proper reporting; reinforce the position of coordination committees or health committees for linking community level to health center and post levels. Also, facing inefficiency of the systems in place, some propose to harmonize the system by following a single supply path whereas others would tend towards a standalone drugs distribution for community health.

RESULTSSupply Chain


6.3. Appropriate medicines for community case management

CHWs are usually provided with the appropriate medicines meeting WHO/UNICEF recommendations, but some exceptions can be noticed, such as Congo that states that antibiotics use would be narrowed to cotrimoxazole, Senegal that does not precise which antibiotic should be used, and some countries that recommend traditional remedies besides antibiotics for IRA/pneumonia management (honey herbal tea with lemon in Côte d’Ivoire and Balembo syrup in Mali). Also, it appears that child-friendly medicines are the recommended formulations in most of countries; however only 4 countries (Chad, DRC, Niger, and Nigeria) specify, in the policy documents, the Dispersible Tablet (DT) form of amoxicillin to be the one recommended.

The integration of such medicines in the national essential medicines list are never specified, but on the other hand, Nigeria states that policy change will be affected so that the iCCM medicines that are not yet listed as over-the-counter drugs (such as the amoxicillin DT) will be so listed.

RESULTSSupply Chain


7. REFERRAL AND COUNTER-REFERRAL

7.1. Definition of referral and counter-referral mechanisms in policy documents

Regarding appropriate guidelines for clinical assessment, diagnosis, management and referral, the existence and use of job aids and other material are hardly ever mentioned in the policy documents.

Referral and counter-referral system is, however, briefly reported in four countries policy documents (CAR, Mali, Mauritania, and Nigeria) but is very detailed in Ghana’s implementation guidelines.

7.2. Existence of clearly define mechanisms

18 countries, out of 20, state that CHWs can refer to appropriate tools for clinical assessment, diagnosis, management and referral, which mostly include CHWs training modules, handbooks, job aids, possibly including decision trees, graphics, image box, or any other visual aid. Nigeria do not have ones and Chad notifies that such tools are being developed.

The community health referral procedure includes written process in 19 countries, verbal process in seven, and accompanying the patient in 15. Six countries referral process - Chad, Côte d’Ivoire, Liberia, Mauritania, Niger, and Togo - encompasses the three procedures. However, in all countries, the referred cases are always indicated in CHWs reports.

7.3. Counter-referral16 countries have a counter-referral mechanism in place - Chad, Mauritania, Nigeria, and Senegal do not have one. The process, when in place, mainly consists in counter-referral forms. Also, sometimes, feedback regarding justification and necessity of referred cases is provided during monthly supervision meetings, like in Benin and Mali. On the other hand, Ghana and Guinea Bissau point out that, as a matter of fact, the counter-referral mechanism is not always effective.

RESULTSReferral and counter-referral


8. COMMUNICATION AND SOCIAL MOBILIZATION

8.1. CommunicationAccording to the policy documents, two countries seem to have an existing communication plan (CAR, Nigeria). Two countries (Liberia, Niger) do not mention a plan but list practices for communication to be used at community level, and two more countries do not have either a detailed communication plan appearing through the policy but focus on specific aspects: C4D is a full strategic area in Congo’s policy, and community engagement is very detailed in Ghana’s implementation guidelines.

Besides, seven countries mention in the policy documents the use of communication material for CHWs (job aid, image box, leaflet, etc.), or have shared them with the research team during the first step of the review.

Finally, seven countries state in their policy documents that a communication plan will be developed later on.

8.2. Community engagementA national strategy for community engagement exists in 16 countries; it is part of the community health policy in 12 countries, of the health policy in seven (of which six are among the ones having also integrated it in the community health policy, plus The Gambia that only has a health policy including community health guidance), and is included in the community-based interventions policy in six countries. Ghana, Guinea, and Niger have the strategy included in all of these documents. On the contrary, Cameroon, Guinea Bissau, Nigeria, and Togo do not have any strategy

for community engagement. The strategy for community engagement may also be integrated in other documents, such as “Integrated communication plan for maternal, newborn, and child health” in Benin, or “Maternal and Child Nutrition and Health Result Project Community Mobilization Strategy” in The Gambia.

Figure 38- Existence of a community engagement plan and where it belongs in the policy documents in WCAR countries

16

12

76

Existe

nce

of

com

mun

ity

enga

gem

ent p

lan

Part o

f com

mun

ity

healt

h po

licy

Part o

f hea

lth p

olicy

Part o

f

com

mun

ity-b

ased

inter

vent

ions p

olicy

Num

ber

of c

ount

ries

8.3. Accountability frameworkAccountability framework and structures at all levels exist in 12 countries, but Cameroon draws attention to the fact that this is not functional.

8.4. Community capacitiesBased on the responses from countries, communities are able to take leadership in health issues in 16 countries, partially in Mauritania, and not at all in Cameroon, Guinea Bissau, and Nigeria. Communities can get involved in planning, monitoring, and evaluation of interventions in 18 countries (all countries except for Guinea Bissau and Nigeria). Communities can solve

RESULTSCommunication and social mobilization


problems at local level in all countries, except for Guinea Bissau. Finally, communities can carry out resource mobilization in 15 countries (not in Congo, Guinea Bissau, Nigeria, Sierra Leone, and Togo). In summary, communities have an interesting degree of involvement in health matters in 14 countries, whereas in Guinea Bissau it is stated that “although their leadership is promoted by partners and Ministry, they are completely inactive”. Figure 39- Number of WCAR countries that acknowledge the four specified community capacities

1618 19

15

Take

leade

rship

in

healt

h iss

ues

Get in

volve

d in

plann

ing,

mon

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g, an

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aluat

ion

of in

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entio

ns

Solve

prob

lems

at lo

cal le

vel

Carry

out

reso

urce

mob

ilizat

ion

Num

ber

of c

ount

ries

8.5. Multisectoral dynamic at community levels

Regarding acknowledgement of other stakeholders at community level, community health policy and/or communication plan mention volunteers other than CHWs in only nine countries, community-based structures in 13 countries, and CSOs in 16 countries. Overall, six countries - CAR, Chad, The Gambia, Guinea, Mali, and Senegal - make a reference to all of these entities in the policy or communication documents.

RESULTSCommunication and social mobilization


9. SUPERVISION AND PERFORMANCE QUALITY ASSURANCE

9.1. Policy reviewOnly 40% of countries (8 in 20) seem to have a comprehensive supervision plan that is referred to in the policy documents, 10% (2 in 20) have incomplete ones, and another 40% do not have any, but two of them are planning to develop one.

According to the content of countries’ policy documents that are exposing supervision features, supervision frequency varies from once a month (35%) to twice a month (25%). Special cases can be highlighted here: supervision is carried out on site during the first 6 months of CHWs activity and then supervision is integrated to program’s supervision; this process proposed in 2 countries: Guinea Bissau and Mali.

Supervisors are usually the chiefs of the health area or trained health workers from the health facility which CHWs depend on. Special case can also be highlighted here: in Sierra Leone, peer supervisors (not required to act as CHWs since the last policy) supplement supervision by the Peripheral Health Unit in charge, and in Côte d’Ivoire, coach CHW is a full-package CHW who is also responsible for the supervision of a dozen basic CHWs in the health area.

It is important to note that, even though the policy documents are not specific, all the 20 countries assert in the qualitative survey that they have established a supervision plan.

9.2. Supervision and performance quality assurance practices in countries

Supervisor/supervisees ratioThe supervisor/supervisees ratio highly differs from one country to another. Whereas the ratio is indeterminate in Burkina Faso, Chad, Nigeria,

and Senegal, some countries have established precise ratio of supervisor to supervisees, which is 1 to 45 in Guinea Bissau, 1/12 in Benin; 1/8 in Cameroon; 1/5 in Congo, Mauritania, and Niger; 1/10 in Côte d’Ivoire, Guinea, Liberia, and Sierra Leone.In Togo, in addition to one health facility manager supervising 5 CHWs, there is also 1 volunteer supervisor recruited by the national volunteer program supervising 20 CHWs. Some others have more variable ratios, such as one team of local supervisors to 10 to 20 CHWs in Mali; 1 CHN or CHO to 2 to 10 CHVs/CHWs in Ghana; or one CHN/Village Health Supervisor to 5 to 9 villages (each village having at least one Community Birth Companion and one Village Health Worker) in The Gambia.

Supervisors profileAlmost all countries (18/20) have CHWs supervised by a health facility staff. Most often, the persons in charge of supervision are nurses and midwives from the health facility or the facility-in-charge or the manager of the health area. In addition to the supervisors from health facility, we also find particular cases like itinerant health officers in Burkina Faso, and Community Health Services Supervisors in Liberia (that share their time between health facilities (40%) and communities (60% supervising CHAs). Also, in DRC, the President of the health area committee is involved in supervision. Supervisors at community level may also be found, like in Niger (volunteers from the Nigerien Agency for Volunteering for Development), Togo (volunteers hired by the national agency for volunteer service) or DRC (community organizer of the health area).

Finally, supervision from district, region, and central levels also takes place in many countries on a quarterly or biannual basis.

Countries where no supervision is made from health facility are Ghana where CHVs are supervised by CHOs and CHOs are supervised by the Sub-District Head, and Mali where supervisors are the Technical Director of the Community Health Center (CSCOM) or Community Health

RESULTSSupervision and performance quality assurance


Organizations (ASACO). Côte d’Ivoire is planning to have Coach CHWs that are specific CHWs providing services at community level and also in charge of supervising about 10 Basic CHWs.

Table 3- Identity of CHWs supervisors in WCAR countries

COUNTRY Supervisors from health facility

Other supervisors

BENIN Nurse / Midwife / Assistant nurse / Environmental health officer

Community

BURKINA FASO

Itinerant health officer / All health facility staff (if needed) – nurse, midwife, etc.

CAMEROON Manager of the health area

CAR Chief nurse

CHAD Health center manager

Community

CONGO Nurse / Health assistant / Doctor

Community

CÔTE D’IVOIRE

Nurse / Midwife

DRC Chief nurse / Health area supervisor nurse / Health area manager

President of the health area committee / Community organizer of the health area

GAMBIA, THE Community health nurse

GHANA CHOs supervise CHVs / Sub-district head supervises CHOs

GUINEA Facility-in-charge or deputy

GUINEA BISSAU

Manager of the health area / Field operations supervisor

LIBERIA Community health services supervisor

MALI Chief nurse Technical Director of the Community Health Center (CSCOM) or Community Health Organizations (ASACO)

MAURITANIA Health center manager / Health hut manager

NIGER Volunteers from the Nigerien Agency for Volunteering for Development

NIGERIA Facility-in-charge

SENEGAL Chief nurse / Midwife

Health committee / Community

SIERRA LEONE

PHU staff / Chiefdom supervisor

Community

TOGO Nurse / Auxiliary birth attendant / Senior health technician / Doctor

Supervision tools and resourcesIn all countries, supervision tools specific to community health are declared to be used. Also, 17 countries, out of 20, agree that resources




are available to conduct supervision and provide coaching skills to CHWs. Nevertheless, almost all of them specify that resources are inadequate. Also, Benin, Côte d’Ivoire, Mali, Niger, and Togo highlight that these resources are highly dependent on partners, which questions the sustainability of these supervision activities. Cameroon, Congo, and Nigeria do not think at all that adequate resources for supervision are available.

Supervision frequencyIn almost all countries (18/20) CHWs must submit a report every month. In Côte d’Ivoire an additional report is also submitted on a quarterly basis. Exceptions to the monthly frequency are for Mauritania, where it is a bit longer (every 45 days), and for Nigeria where, on the contrary, CHWs have to report every week.


Innovative patterns of supervision

Supervision is an important aspect that impacts both CHWs motivation and skill building. In most of the countries, supervision is performed by the nurse head of facility, or the chief of the health area. However, some examples can be mentioned as innovative ways to carry out supervision in order to fill in the supervision gaps:

- Volunteers hired by national volunteer service agencies and deployed in the community, like in Niger, Togo, and DRC, can be an interesting option to address the lack of time persons in charge at facility level can dedicate to supervising CHWs.

- The example of Burkina Faso’s model of supervision seems comprehensive, since supervision of CHWs is carried out by itineran health workers, which could address the time and long distance needed to reach all CHWs. Also, this supervision is supplemented by community-based organizations that has contracted community-based health services with the Ministry of Health.

- Also, the new organization and status of CHWs in Côte d’Ivoire, to be implemented soon, that involves training some performant CHWs to be supervisors for other basic CHWs seems to be a great opportunity, on the one hand to reinforce the supervision at local level, and on the other hand to empower and recognize worthy CHWs.

Box 4: Innovative patterns for supervision


RESULTSMonitoring and evaluation and community health information systems


9. Source: https://dhis2.github.io/dhis2-in-action/

10. MONITORING AND EVALUATION AND COMMUNITY HEALTH INFORMATION SYSTEMS

10.1. Policy reviewRegarding Monitoring & Evaluation (M&E) system, 35% of country policies state that a plan will be developed, another 35% seem to have one but none of them is a comprehensive one - either mechanism/baseline/expected results are lacking, or list of indicators is not comprehensive.

10.2. Monitoring frameworkThree quarters of countries (15/20) report that they have a comprehensive monitoring framework and system in place. Development of such a framework is still in progress in Cameroon, but Chad, Congo, Côte d’Ivoire, and Mauritania do not have one yet.

The robustness of the system is here assessed upon the presence of several components: well-defined indicators, baseline indicators, expected results with quantified target and precise deadline, clear and detailed mechanism (tools, frequency and level of data collection), and means of using information. All 15 countries that have developed a monitoring framework state that the system includes well-defined indicators, but only 10 of them have baseline indicators included. The system includes expected results in only nine countries. The system of 14 countries include clear and detailed mechanism. 12 of them also state that means to orient use of data are taken into account in the monitoring framework. Ultimately, only eight countries - CAR, DRC, Guinea, Niger, Nigeria, Senegal, Sierra Leone, and Togo - hold a comprehensive monitoring system that meets all the essential components described above.

10.3. Integration of community health data into national information system

Community health data of 14 countries are integrated within the national health information system, but community data are disaggregated until the end of the national health information system in only six of them - Benin, The Gambia, Ghana, Liberia, Nigeria, and Sierra Leone - and disaggregation is in progress in Senegal.

Figure 40- Integration of community health data into the national health information system and disaggregation of data

integrated in the national health informationsystem and disaggreated until the end of the system

integrated in the national health information system and disaggregation in progress

integrated in the national healthinformation system

Community health data

DigitalizationCommunity health data transmission remains paper-based at least at community level in all countries. Transmission is also digitalized at some higher levels in eight countries (Burkina Faso, The Gambia, Ghana, Guinea Bissau, Liberia, Nigeria, Senegal, and Sierra Leone). When digitalized, community health information system is DHIS2 based. DHIS2 software is used by 17 countries in the region, three in a pilot phase and 14 at national scale9; however, only 2 (Benin and Cameroon) mention it in the policy


documents.Figure 41- Use and stage of implementation of DHIS2 in WCAR countries in 2017

implementation in pilot phase

implementation at national scale

Scale of implementation of digitalized transmission for community health data is variable from six districts in Burkina Faso to two states in Nigeria (planning to scale-up to 10 states by the end of 2018), to a national coverage in some countries such as The Gambia, Liberia, Senegal, and Sierra Leone. Technology used for transmission includes cell phones in several countries - e.g. Burkina Faso, Nigeria (in addition to tablets), and Senegal. Web-based real-time data (implemented in The Gambia, Ghana, and Liberia), allows for an online access to data - not always accessible to all stakeholders, yet.

Data consolidationThe persons responsible for community health data consolidation differ from country to country. Most often it is the manager of the health center or of the health area (for instance the chief nurse of health post in Benin, Côte d’Ivoire, DRC, Senegal, or the manager of the health area in Guinea Bissau). Sometimes, specific agents are in charge of data consolidation, like the District Health Information Officer in Ghana, the Data Entry Clerk to County M&E Officers in Liberia, or the Technical Director of CSCOM

in Mali. Cameroon and Senegal also report that partners from CSOs may sometimes be the ones consolidating community data as they are the ones paying CHWs (as the validation of report determines payment), while specifying that the chief nurse should actually be the one validating data.

10.4. Research plansFinally, only seven countries report having elaborated an operations research plan, namely CAR, Ghana, Liberia, Mali, Niger, and Sierra Leone; but only Congo and Nigeria expose a plan for operational research in their policy document. However, in most cases, the plan does not seem concrete yet since specific objectives and research institutions involved are not often specified.

RESULTSMonitoring and evaluation and community health information systems


These findings, and through them the content of policies, mark some important trends for community health. First, this survey confirms previous findings about development and expansion of community health policies [6]. Almost all countries have now at least one community health official document (and most often several documents), including policy, strategic plan, action plan, or guidelines. Also, a coordination structure for community health at central level has become very common, as well as national multisectoral committees, although meetings are not always operative. Second, should be highlighted tendency of growing involvement of communities in management of health at local level, that could be supported by social mobilization and community participation [9]. Third, we can notice a real trend towards harmonization and simplification of CHW cadres at national level, while still taking into account the context specific approaches and the history of CHW cadres’ nature in each country. Fourth, the package of services provided by CHWs looks now a lot beyond iCCM and management of pneumonia, diarrhea, and malaria, and tends to include other services - such as family planning, HIV, community-based surveillance, etc.- and new targets such as newborns and adolescents.

However, some lingering issues may also be raised. Even though the cornerstones of community health are now more and more well described (e.g. types and status of CHWs, supervision plans, monitoring frameworks, etc.), their implementation has not always advanced in every country yet. For instance, as it was the case in the 2013 survey, several countries were not able to give some implementation figures such as number of CHWs or attrition rate, since the recruitment of the cadres described has not begun yet [5,6]. As well, we can sometimes understand that the CHWs remuneration provided by the policy documents are not always in place yet, partly because of partners still covering these aspects and not always aligning on amounts defined at national level. Moreover, overall financing remains an issue for sustainability

of programs [5]. Even though most of countries have costed the program, only a few ones have a financing plan securing it. Also, only a minority of countries commit domestic resources through a national budget line dedicated to community health - and even when it is the case, the amount of the budget line or its proportion within the national health budget cannot be specified; and when it is, there is often no increase between the 2016’s and 2017’s amount, and no plan to improve it is stated. Another point of concern regarding financing aspects is user fees, which occur in only a few countries regarding CHWs consultations but in more cases regarding drugs and supplies for services offered by CHWs. This issue, that mainly concern West Africa countries, might still stand in the way of achieving access to health for all, including universal health coverage and Sustainable Development Goals (SDGs) [6, 8].

Regarding the package of services, as it is expanding, there are still opportunities for strengthening and extension, but it will be essential, on the one hand to take into account the growing workload of CHWs, as well as the gender dimensions, and on the other hand to support the addition of activities with evidence generated by research focusing on effectiveness, impact, and harmlessness - for instance the debate on the involvement of CHWs with persons living with HIV has not been settled, and further discussion is needed since CHWs are no subject to professional secrecy.

Status and remuneration of CHWs remain issues of high importance to address. Except for a few countries, CHWs are still called community volunteers and do not enjoy a strong status; and even when they have been identified as having a specific status (for instance contract workers) they seldom are protected by an employment contract. Concurrently, either because of willing CHWs to remain volunteers as a matter of principle, or because of the lack of resources, some countries still have unpaid workers who, despite being given some benefits in kind, earn at best monthly incentive, while they often have

DISCUSSION


DISCUSSION

to devote most of day all month long to their CHW activities. Furthermore, heated debate is still on-going about benefits and drawbacks of volunteerism [6]. Also, gender dimensions are hardly ever taken into account. In the West and Central Africa region, CHWs are mainly male but not only gender-responsiveness of policies is still inadequate, but also questioning about these unbalanced ratios is insufficiently raised.

This kind of survey is quite important to gather data and establish a picture of community health systems, but it remains essential to strengthen information systems and to integrate community health data into them to institutionalize data collection and use, and to be able to measure quality of services, as well as impact of the strategies on an ongoing basis. Gaps in knowledge that have been raised here, regarding important aspects such as number of CHWs and sex ratio, and scale of implementation of the various components of the package of services of CHWs, could suggest on the one hand that availability of data is not optimum and that community health information systems need to be strengthen, and on the other hand that leadership of governments over partners in the implementation of some services might still be questioned.

This survey presents some limitations. First, the questionnaire has been completed by national specialists (most of the time officials from Ministry of Health and only UNICEF staff); thus, the responses reflect their opinion, but the extent to which the responses have been supported with specific data is pretty unknown, and is also highly depending on availability of these data at national level. Second, due to lack of time, no pretest of the questionnaire can have been performed. Hence, some questions might have been misunderstood and could not be rephrased or specified - such as the ones related to gender issues, accountability framework, the relation between Ministry of Health and local governance, or the community health centers and community-based facilities. Also, some answers may raise concerns about completeness

or quality of data. However, verification through reviewing of responses and asking clarification to UNICEF respondents have been undertaken as far as possible.


CONCLUSION

Great progresses have been achieved since the emergence of iCCM, and also since the 2013 survey, regarding many aspects of institutionalizing community health such as development of policy documents, creation of coordination framework, and implementation of multisectoral approaches. Also, the concept of community systems supported by strong community engagement in order to make communities accountable for their own health is clearly spreading in the policies. However, some key gaps need to be urgently addressed in order to ensure sustainability of the programs. Among the most important, we can name CHWs status, workload, and motivation, gender responsiveness of the policies, financing, and strengthening of community health information systems.

The results of this survey will be completed and reinforced by other assessments, including CHIS assessment and gender anthropological analysis of community health, in order to get a full picture of community health today, and establish comprehensive and strong priorities for action towards institutionalizing community health in West and Central Africa.


1. The State of the World’s Children 2016: A fair chance for every child. New York: UNICEF, 2016.

2. Young M, Wolfheim C, Marsh DR, Hammamy D. World Health Organization/United Nations Children’s Fund joint statement on integrated community case management: an equity-focused strategy to improve access to essential treatment services for children. Am J Trop Med Hyg. 2012; 87:6-10.

3. Sanders D. Background paper for Regional workshop on integrated community-based maternal, newborn and child health and nutrition interventions. Dakar: Harmonization for Health in Africa, 2011.

4. Pfaffmann Zambruni J, Rasanathan K, Hipgrave D, Miller NP, Momanyi M, Pearson L, Rio D, Romedenne M, Singh S, Young M, Peterson S. Community health systems: allowing community health workers to emerge from the shadows. Lancet Glob Health. 2017 Sept; 5(9): e866-e867.

5. Rasanathan K, Bakshi S, Rodriguez DC, Oliphant NP, Brandes N, Jacobs T, et al. Where to from here? Policy and financing of integrated community case management of childhood illness (iCCM) in sub-Saharan Africa. J Glob Health. 2014; 4:020304.

6. Rasanathan K, Muñiz M, Bakshi S, et al. Community case management of childhood illness in sub-Saharan Africa: findings from a cross-sectional survey on policy and implementation. Journal of Global Health. 2014; 4: 020401.

7. Bennett S, George A, Rodriguez DC, Shearer J, Diallo B, Konate M, et al. Policy challenges facing integrated community case management in Sub-Saharan Africa. Trop Med Int Health. 2014; 19:872-82.

8. Meessen B, Gilson L, Tibouti A. User fee removal in low-income countries: sharing knowledge to support managed implementation. Health Policy Plan. 2011;26 Suppl 2:ii1-4.

9. Sharkey AB, Berzal R, Wetzler E, Cerveau T, Martin S. Demand generation and social mobilisation for iCCM and child health: Lessons learned from successful programmes in Niger and Mozambique. J Glob Health. 2014; 4:020410.

REFERENCES


ANNEXES


ANNEX ACountry profiles

BE

NIN

CO

OR

DIN

ATI

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A

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EN

VIR

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Yes

Yes

No

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Yes

Yes

Yes

Yes

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Yes

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No

Yes

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N

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Yes

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Yes

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PE

RS

ON

S IN

NE

ED

RE

CE

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G C

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AG

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INTE

RV

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in %

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MM

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Pre

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regn

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amily

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isfied

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moder

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nus pro

tecti

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Pregnan

t wom

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ing

with H

IV re

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re fo

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Populatio

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32%

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86%

83%

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71%

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61%

58%

94%

89%

87%

90%

6%

49%

19%

63%

14%

Leve

lN

ame

S

tatu

sC

ontr

act

Pay

E

duca

tion

leve

l re

quire

dP

re-s

ervi

ce t

rain

ing

dura

tion

Firs

tC

omm

unity

Hea

lth

Wor

ker

--

Mot

ivat

ion/

per

di

em

Rea

ding

and

ca

lcul

atio

n10

day

s

Sec

ond

Rel

ayC

omm

unity

vo

lunt

eer

-M

otiv

atio

n/ p

er

diem

R

eadi

ng a

nd

calc

ulat

ion

10 d

ays


ANNEX BRegional profile

AA

A


AN

NE

X C

.1 -

CO

OR

DIN

ATI

ON

AN

D P

OLI

CY

EN

VIR

ON

ME

NT

CO

UN

TRY

C

om

mu

nit

y h

ealt

h p

olic

y O

ther

co

mm

un

ity

hea

lth

sp

ecifi

c d

ocu

men

tC

oo

rdin

atio

n s

tru

ctu

re

Nat

ion

al m

ult

isec

tora

l co

mm

itte

e

BE

NIN

Yes

Yes

Yes

No

BU

RK

INA

FA

SO

No

Yes

Yes

Yes

CA

ME

RO

ON

Yes

Yes

Yes

Yes

CA

RN

oYe

sYe

sYe

s

CH

AD

Ye

sYe

sYe

sYe

s

CO

NG

OYe

sYe

sYe

sN

o

CÔ

TE D

’IVO

IRE

No

Yes

Yes

No

DR

CN

oYe

sYe

sYe

s

GA

MB

IA, T

HE

In p

rogr

ess

No

Yes

Yes

GH

AN

AYe

sYe

sYe

sYe

s

GU

INE

AYe

sYe

sYe

sN

o

GU

INE

A B

ISS

AU

Yes

Yes

Yes

No

LIB

ER

IAYe

sYe

sYe

sN

o

MA

LIN

oYe

sYe

sYe

s

MA

UR

ITA

NIA

No

Yes

Yes

Yes

NIG

ER

No

Yes

Yes

Yes

NIG

ER

IA

In p

rogr

ess

Yes

Yes

No

SE

NE

GA

LYe

sYe

sYe

sYe

s

SIE

RR

A L

EO

NE

Yes

Yes

Yes

Yes

TOG

O

Yes

Yes

Yes

Yes

ANNEX CTables of main community health criteria in West and Central African countries


AN

NE

X C

.2 -

CO

STI

NG

AN

D F

INA

NC

ING

CO

UN

TRY

Co

st e

stim

atio

n o

f co

mm

un

ity

hea

lth

p

rog

ram

(U

S$)

Fin

anci

ng

pla

n

Co

mm

un

ity

hea

lth

sp

ecifi

c b

ud

get

lin

eFr

ee C

HW

co

nsu

ltat

ion

Fr

ee C

HW

ser

vice

s d

rug

s an

d s

up

ply

BE

NIN

66,9

40,7

80 /

5 ye

ars

No

No

Yes

Onl

y fo

r so

me

serv

ices

BU

RK

INA

FA

SO

17,7

08,3

22 /

3 ye

ars

Yes

Yes

Yes

Onl

y fo

r so

me

serv

ices

CA

ME

RO

ON

174,

733

/ 3 y

ears

No

Yes

Yes

Onl

y fo

r so

me

serv

ices

CA

RN

oN

oYe

sYe

s Ye

s

CH

AD

1,

488,

798,

678

/ 4 y

ears

N

oN

oYe

sYe

s

CO

NG

O2,

192,

904

/ 5 y

ears

No

No

Yes

Yes

CÔ

TE D

’IVO

IRE

No

No

No

Yes

Onl

y fo

r so

me

serv

ices

DR

CIn

pro

gres

sN

oYe

sYe

sYe

s

GA

MB

IA, T

HE

Unk

now

n N

oYe

sN

oN

o

GH

AN

AU

nkno

wn

No

No

Yes

No

GU

INE

A60

,000

,000

/ 5

year

s Ye

sN

oN

oN

o

GU

INE

A B

ISS

AU

47,8

62 /

5 ye

ars

No

No

Yes

Yes

LIB

ER

IA10

4,00

0,00

0 / 6

yea

rsN

oN

oYe

sYe

s

MA

LI29

,419

,900

/ 5

year

s N

oN

oYe

s10

Onl

y fo

r so

me

serv

ices

MA

UR

ITA

NIA

1,48

8,47

2 / 3

yea

rs

No

Yes

No

Onl

y fo

r so

me

serv

ices

NIG

ER

1,36

2,81

8 / 1

yea

rN

oN

oYe

sYe

s

NIG

ER

IA

No

No

No

Yes

Onl

y fo

r so

me

serv

ices

SE

NE

GA

LU

nkno

wn

No

Yes

Yes11

O

nly

for

som

e se

rvic

es

SIE

RR

A L

EO

NE

108,

900,

000

/ 5 y

ears

Ye

sYe

sYe

sYe

s

TOG

O

29,7

31,5

77 /

5 ye

ars

No

Yes

Yes

Yes

10. O

nly

conc

erns

som

e se

rvic

es -

birt

h re

gist

ratio

n an

d se

rvic

es t

o th

e in

dige

nt

11. O

nly

conc

erns

ser

vice

s pr

ovid

ed b

y D

SD

OM

to

child

ren

unde

r fiv

e



AN

NE

X C

.3 -

HU

MA

N R

ES

OU

RC

ES

3.

1 G

ener

al c

onsi

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tions

CO

UN

TRY

Mo

re t

han

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ents

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io (

fem

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mal

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end

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esp

on

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co

mm

un

ity

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lth

p

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y

BE

NIN

Yes

40/6

0N

o

BU

RK

INA

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SO

No

32/6

8Ye

s

CA

ME

RO

ON

Yes

Unk

now

nN

o

CA

RYe

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ale

> f

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eYe

s

CH

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Ye

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50/5

0 (1

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and

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in e

ach

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s

CÔ

TE D

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IRE

Yes

20/8

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s

DR

CYe

s30

/70

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GA

MB

IA, T

HE

Yes

55/4

5 (m

ainl

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omen

CB

Cs)

No

GH

AN

AYe

s20

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INE

AYe

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Yes

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INE

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ISS

AU

No

Unk

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ER

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(hig

hly

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ble

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g re

gion

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s

MA

LIN

o1.

5Ye

s

MA

UR

ITA

NIA

Yes

Fem

ale

> m

ale

No

NIG

ER

Yes

Mal

e >

fem

ale

Yes

NIG

ER

IA

Yes

Unk

now

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A12

SE

NE

GA

LYe

sU

nkno

wn

No

SIE

RR

A L

EO

NE

No

35/6

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s

TOG

O

Yes

Unk

now

n Ye

s

12. N

iger

ia c

onsi

dere

d th

e qu

estio

n no

t ap

plic

able

sin

ce t

here

is n

o co

mm

unity

hea

lth p

olic

y in

eff

ect

yet



AN

NE

X C

.3 -

HU

MA

N R

ES

OU

RC

ES

3.

2 Fi

rst

leve

l of

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CO

UN

TRY

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ame

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act

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Pre

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du

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Qua

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mun

ity

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alar

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econ

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3

year

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mun

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ased

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ker

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ary

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day

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ckag

e

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otiv

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and

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days

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C

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Per

form

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ch C

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Sta

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mot

ivat

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PB

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ding

and

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lcul

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n7

days

GA

MB

IA, T

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Com

mun

ity H

ealth

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alar

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GH

AN

AC

omm

unity

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Offi

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(CH

O)

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defin

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ary

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onda

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HO

2 y

ears

& 2

w

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/ C

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24 w

eeks

GU

INE

AC

HW

Civ

il se

rvan

t -

Sal

ary

Sec

onda

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year

s

GU

INE

A B

ISS

AU

CH

W-

Mot

ivat

ion

Prim

ary

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ays

LIB

ER

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unity

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lth

Ass

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nt (C

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)S

tate

vol

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ce

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ivat

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ding

and

ca

lcul

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8 da

ys

MA

LIC

HW

Inde

finite

dur

atio

nS

alar

y/ m

otiv

atio

nP

rimar

y 21

day

s



AN

NE

X C

.3 -

HU

MA

N R

ES

OU

RC

ES

3.

2 Fi

rst

leve

l of

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W

CO

UN

TRY

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ame

Sta

tus

Co

ntr

act

Pay

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du

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on

le

vel r

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ired

Pre

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vice

tr

ain

ing

du

rati

on

MA

UR

ITA

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WS

tate

vol

unte

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Per

die

m/ m

argi

n on

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ale

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ays

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Rel

ay w

ith

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vol

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per

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and

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day

s

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ER

IA

Com

mun

ity H

ealth

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xten

sion

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(CH

EW

)

Civ

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SE

NE

GA

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mon

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Mot

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per

di

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Rea

ding

and

ca

lcul

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n10

day

s



AN

NE

X C

.3 -

HU

MA

N R

ES

OU

RC

ES

3.

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econ

d le

vel o

f C

HW

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UN

TRY

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ame

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act

Pay

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du

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Pre

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Rel

ayC

omm

unity

vol

unte

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rman

ce

PB

F/ m

otiv

atio

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per

diem

P

rimar

y 11

day

s

BU

RK

INA

FA

SO

--

--

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CA

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Psy

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per

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te v

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/ NG

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volu

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er d

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Varia

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CO

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OR

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Per

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l pa

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7 da

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GA

MB

IA, T

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Vill

age

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Wor

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nd

Com

mun

ity B

irth

Com

pani

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BC

)

Sta

te v

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teer

/ co

mm

unity

vol

unte

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Mot

ivat

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per

di

em

Non

e28

day

s

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AN

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omm

unity

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Volu

ntee

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unity

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unte

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ays

GU

INE

AR

elay

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te c

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and

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s

GU

INE

A B

ISS

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--

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LIB

ER

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omm

unity

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mot

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Non

e

MA

LI-

--

--

-



AN

NE

X C

.3 -

HU

MA

N R

ES

OU

RC

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3.

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econ

d le

vel o

f C

HW

CO

UN

TRY

N

ame

Sta

tus

Co

ntr

act

Pay

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du

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Pre

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du

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MA

UR

ITA

NIA

Rel

ayS

tate

vol

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GO

vo

lunt

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Per

die

m

Prim

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NIG

ER

Rel

ay w

ith p

rom

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and

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volu

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IA

Com

mun

ity O

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Res

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O c

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finite

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alar

y P

rimar

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SE

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ox, a

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ition

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volu

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R

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ion

40 to

55

days

SIE

RR

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--

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Rel

ayC

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unity

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di

em

Rea

ding

and

ca

lcul

atio

n10

day

s



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.1

Geo

grap

hic

cove

rage

/ P

art

1

CO

UN

TRY

A

nte

nat

al a

nd

new

bo

rn c

are

Ch

ildh

oo

d il

lnes

ses/

iCC

M

Ad

ole

scen

t Fa

mily

pla

nn

ing

BE

NIN

Par

tially

in a

ll di

stric

ts

Par

tially

in a

ll di

stric

ts-

Par

tially

in 5

/34

dist

ricts

BU

RK

INA

FA

SO

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

-Fu

lly in

all

dist

ricts

CA

ME

RO

ON

Fully

in 8

0/18

9 di

stric

ts

Fully

in 8

0/18

9 di

stric

tsFu

lly in

80/

189

dist

ricts

Fu

lly in

80/

189

dist

ricts

CA

RP

artia

lly in

9/3

5 di

stric

ts

Par

tially

in 1

1/35

dis

tric

ts

-U

nkno

wn

CH

AD

U

nkno

wn

Unk

now

n U

nkno

wn

Unk

now

n

CO

NG

OP

artia

lly in

22/

53 d

istr

icts

P

artia

lly in

22/

53 d

istr

icts

- 3/

53 f

or c

urat

ive

care

Par

tially

in 2

2/53

dis

tric

ts

Par

tially

in 2

2/53

dis

tric

ts

CÔ

TE D

’IVO

IRE

Par

tially

in a

ll di

stric

ts

Par

tially

in a

ll di

stric

tsP

artia

lly in

all

dist

ricts

P

artia

lly in

all

dist

ricts

DR

CU

nkno

wn

Unk

now

n U

nkno

wn

Unk

now

n

GA

MB

IA, T

HE

Fully

in a

ll P

HC

vill

ages

Fu

lly in

all

PH

C v

illag

esFu

lly in

all

PH

C v

illag

es f

or

all a

ctiv

ities

- H

PV

vac

cine

in

1 r

egio

n

Fully

in a

ll P

HC

vill

ages

GH

AN

AFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

-Fu

lly in

all

dist

ricts

GU

INE

AFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

Fully

in a

ll di

stric

ts f

or a

ll ac

tiviti

es e

xcep

t fo

r H

PV

va

ccin

e

Fully

in a

ll di

stric

ts

GU

INE

A B

ISS

AU

Fully

in a

ll he

alth

are

as

Fully

in a

ll he

alth

are

as-

Fully

in a

ll he

alth

are

as

LIB

ER

IAP

artia

lly in

11/

90 d

istr

icts

Fu

lly in

79/

90

Par

tially

in 1

1/90

dis

tric

ts

Fully

in 7

9/90

Par

tially

in 1

1/90

dis

tric

ts

Fully

in 7

9/90

P

artia

lly in

11/

90 d

istr

icts

Fu

lly in

79/

90

MA

LIFu

lly in

47/

65 d

istr

icts

Fu

lly in

47/

65 d

istr

icts

Fully

in 4

7/65

dis

tric

ts

Fully

in 4

7/65

dis

tric

ts

MA

UR

ITA

NIA

Fully

in a

ll m

ough

ataa

sFu

lly in

all

mou

ghat

aas

-Fu

lly in

all

mou

ghat

aas

NIG

ER

Fully

in a

ll di

stric

ts

Par

tially

in 1

9/72

dis

tric

ts

--

NIG

ER

IA

Fully

in a

ll LG

As

Fully

in a

ll LG

As

Fully

in a

ll LG

As

Fully

in a

ll LG

As

SE

NE

GA

LFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

SIE

RR

A L

EO

NE

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

tsFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

TOG

O

Unk

now

n Fu

lly in

22/

41 d

istr

icts

-

Par

tially

in 5

/41

dist

ricts



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.1

Geo

grap

hic

cove

rage

/ P

art

2

CO

UN

TRY

H

IVTu

ber

culo

sis

Co

mm

un

ity-

bas

ed s

urv

eilla

nce

BE

NIN

Par

tially

in a

ll di

stric

ts

Par

tially

in a

ll di

stric

ts

Par

tially

in a

ll di

stric

ts

BU

RK

INA

FA

SO

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

CA

ME

RO

ON

Par

tially

in 8

0/18

9 di

stric

ts

Par

tially

in 8

0/18

9 di

stric

ts

Fully

in 8

0/18

9 di

stric

ts

CA

RU

nkno

wn

-U

nkno

wn

CH

AD

U

nkno

wn

Unk

now

n U

nkno

wn

CO

NG

OP

artia

lly in

18/

53 d

istr

icts

-

CÔ

TE D

’IVO

IRE

Par

tially

in a

ll di

stric

ts

Unk

now

n P

artia

lly in

all

dist

ricts

DR

CU

nkno

wn

Unk

now

n U

nkno

wn

GA

MB

IA, T

HE

Fully

in a

ll P

HC

vill

ages

Fu

lly in

all

PH

C v

illag

es

Fully

in a

ll P

HC

vill

ages

GH

AN

AFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

GU

INE

AFu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

GU

INE

A B

ISS

AU

Fully

in a

ll he

alth

are

as

Fully

in a

ll he

alth

are

as

Fully

in a

ll he

alth

are

as

LIB

ER

IAP

artia

lly in

11/

90 d

istr

icts

Fu

lly in

79/

90

Par

tially

in 1

1/90

dis

tric

ts

Fully

in 7

9/90

P

artia

lly in

11/

90 d

istr

icts

Fu

lly in

79/

90

MA

LIFu

lly in

47/

65 d

istr

icts

-

Unk

now

n

MA

UR

ITA

NIA

Fully

in a

ll m

ough

ataa

sFu

lly in

all

mou

ghat

aas

Fully

in a

ll m

ough

ataa

s

NIG

ER

--

Par

tially

in 1

9/72

dis

tric

ts

NIG

ER

IA

Fully

in a

ll LG

As

Fully

in s

ome

LGA

s (n

umbe

r un

know

n)Fu

lly in

som

e LG

As

(num

ber

unkn

own)

SE

NE

GA

LP

artia

lly in

all

dist

ricts

Fu

lly in

all

dist

ricts

P

artia

lly in

17/

76 d

istr

icts

SIE

RR

A L

EO

NE

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

Fully

in a

ll di

stric

ts

TOG

O

-U

nkno

wn

Unk

now

n



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Ant

enat

al a

nd n

ewbo

rn c

are

(unt

il 28

day

s) -

Pro

mot

iona

l act

iviti

es (1

)

CO

UN

TRY

Pro

mo

tio

n a

nd

re

fere

nce

fo

r th

e 4

AN

C v

isit

s

Iro

n/F

olic

aci

dLL

INs

use

PM

TC

T/ E

MT

CT

Del

iver

y w

/ ski

lled

b

irth

att

end

ant

Ski

n t

o s

kin

co

nta

ct

BE

NIN

XX

BU

RK

INA

FA

SO

XX

XX

XX

CA

ME

RO

ON

XX

XX

X

CA

RX

XX

XX

X

CH

AD

X

XX

XX

X

CO

NG

OX

XX

XX

CÔ

TE D

’IVO

IRE

XX

XX

X

DR

CX

XX

XX

X

GA

MB

IA, T

HE

XX

XX

XX

GH

AN

AX

XX

XX

X

GU

INE

AX

XX

XX

X

GU

INE

A B

ISS

AU

XX

XX

X

LIB

ER

IAX

XX

XX

MA

LIX

XX

XX

MA

UR

ITA

NIA

XX

XX

X

NIG

ER

XX

XX

X

NIG

ER

IA

XX

XX

XX

SE

NE

GA

LX

XX

XX

X

SIE

RR

A L

EO

NE

XX

XX

X

TOG

O

XX



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Ant

enat

al a

nd n

ewbo

rn c

are

(unt

il 28

day

s) -

Pro

mot

iona

l act

iviti

es (2

)

CO

UN

TRY

Kan

gar

oo

Mo

ther

Car

e m

eth

od

at

com

mu

nit

y le

vel

Exc

lusi

ve a

nd

ear

ly

bre

astf

eed

ing

P

ost

-par

tum

co

ntr

acep

tio

nB

irth

reg

istr

atio

nIm

mu

niz

atio

n

BE

NIN

XX

X

BU

RK

INA

FA

SO

XX

XX

X

CA

ME

RO

ON

XX

XX

CA

RX

XX

X

CH

AD

X

XX

XX

CO

NG

OX

XX

XX

CÔ

TE D

’IVO

IRE

XX

XX

X

DR

CX

XX

XX

GA

MB

IA, T

HE

XX

XX

X

GH

AN

AX

XX

XX

GU

INE

AX

XX

X

GU

INE

A B

ISS

AU

XX

XX

X

LIB

ER

IAX

XX

X

MA

LIX

XX

XX

MA

UR

ITA

NIA

XX

XX

X

NIG

ER

XX

XX

X

NIG

ER

IA

XX

XX

X

SE

NE

GA

LX

XX

XX

SIE

RR

A L

EO

NE

XX

XX

TOG

O

XX

XX



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Ant

enat

al a

nd n

ewbo

rn c

are

(unt

il 28

day

s) -

Pre

vent

ion

activ

ities

(1)

CO

UN

TRY

Su

pp

ort

du

rin

g la

bo

r in

th

e p

rese

nce

of

a sk

illed

bir

th a

tten

dan

t

Mis

op

rost

ol

adm

inis

trat

ion

to

p

reve

nt

po

st-p

artu

m

hem

orr

hag

e

Ho

me

visi

ts a

fter

d

eliv

ery

(24h

-72h

-7d

)C

ord

car

e E

CD

13

BE

NIN

X

BU

RK

INA

FA

SO

X (o

nly

in 2

8/70

di

stric

ts)

CA

ME

RO

ON

X

CA

R

CH

AD

X

XX

natu

ral d

ryin

g an

d ch

lorh

exid

ine

X

CO

NG

OX

CÔ

TE D

’IVO

IRE

XX

chlo

rhex

idin

e

DR

CX

Xch

lorh

exid

ine

GA

MB

IA, T

HE

XX

natu

ral d

ryin

gX

GH

AN

AX

natu

ral d

ryin

g

GU

INE

AX

XX

chlo

rhex

idin

e

GU

INE

A B

ISS

AU

Xna

tura

l dry

ing

LIB

ER

IAX

MA

LIX

chlo

rhex

idin

e

MA

UR

ITA

NIA

Xna

tura

l dry

ing

X

NIG

ER

XX

Xna

tura

l dry

ing

and

chlo

rhex

idin

e

NIG

ER

IA

XX

natu

ral d

ryin

g an

d ch

lorh

exid

ine

X

SE

NE

GA

LX

XX

natu

ral d

ryin

gX

SIE

RR

A L

EO

NE

Xna

tura

l dry

ing

and

chlo

rhex

idin

eX

TOG

O

13. E

arly

Chi

ldho

od D

evel

opm

ent

(EC

D) w

as d

efine

d he

re a

s an

act

ive

part

icip

atio

n of

CH

Ws

thro

ugh

gam

es, s

ongs

, mas

sage

s, e

tc.



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Ant

enat

al a

nd n

ewbo

rn c

are

(unt

il 28

day

s) -

Pre

vent

ion

activ

ities

(2)

CO

UN

TRY

N

ewb

orn

wei

gh

t co

ntr

ol

New

bo

rn t

emp

erat

ure

co

ntr

ol

Kan

gar

oo

Mo

ther

Car

e at

co

mm

un

ity

leve

l

BE

NIN

BU

RK

INA

FA

SO

XX

supp

ort

CA

ME

RO

ON

CA

Rin

itiat

ion

and

supp

ort

CH

AD

X

Xin

itiat

ion

and

supp

ort

CO

NG

OX

Xin

itiat

ion

CÔ

TE D

’IVO

IRE

Xin

itiat

ion

and

supp

ort

DR

CX

supp

ort

GA

MB

IA, T

HE

Xin

itiat

ion

and

supp

ort

GH

AN

AX

GU

INE

AX

Xin

itiat

ion

GU

INE

A B

ISS

AU

XX

initi

atio

n

LIB

ER

IA

MA

LIX

Xsu

ppor

t

MA

UR

ITA

NIA

XX

initi

atio

n an

d su

ppor

t

NIG

ER

XX

initi

atio

n

NIG

ER

IA

initi

atio

n an

d su

ppor

t

SE

NE

GA

LX

Xin

itiat

ion

and

supp

ort

SIE

RR

A L

EO

NE

X

TOG

O



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Chi

ldho

od il

lnes

ses

(und

er 5

) / iC

CM

- P

rom

otio

nal a

ctiv

ities

CO

UN

TRY

Im

mu

niz

atio

nVa

ccin

atio

n r

eco

rd

con

tro

lN

utr

itio

nal

ed

uca

tio

n14

LLIN

s u

se

EC

D15

BE

NIN

XX

XX

BU

RK

INA

FA

SO

XX

XX

CA

ME

RO

ON

XX

XX

CA

RX

XX

X

CH

AD

X

XX

XX

CO

NG

OX

XX

XX

CÔ

TE D

’IVO

IRE

XX

XX

DR

CX

XX

X

GA

MB

IA, T

HE

XX

X

GH

AN

AX

XX

XX

GU

INE

AX

XX

XX

GU

INE

A B

ISS

AU

XX

XX

X

LIB

ER

IAX

XX

X

MA

LIX

XX

X

MA

UR

ITA

NIA

XX

XX

X

NIG

ER

XX

XX

X

NIG

ER

IA

XX

XX

X

SE

NE

GA

LX

XX

XX

SIE

RR

A L

EO

NE

XX

XX

X

TOG

O

XX

XX

14. I

n al

l cou

ntrie

s, n

utrit

iona

l edu

catio

n in

clud

es e

xclu

sive

bre

astf

eedi

ng u

ntil

6 m

onth

s an

d br

east

feed

ing

until

2. P

rom

otio

n of

you

ng c

hild

fee

ding

is in

clud

ed in

all

of t

hem

, exc

ept

for

Nig

eria

15

. Ear

ly C

hild

hood

Dev

elop

men

t (E

CD

) was

defi

ned

here

as

incl

udin

g on

ly a

ctiv

ities

reg

ardi

ng p

rom

otio

n of

EC

D



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Chi

ldho

od il

lnes

ses

(und

er 5

) / iC

CM

- P

reve

ntio

n ac

tiviti

es

CO

UN

TRY

Pro

visi

on

vit

A

-alb

end

azo

le/

meb

end

azo

le16

Gro

wth

m

on

ito

rin

g

MU

AC

sc

reen

ing

an

d

refe

rral

Dis

trib

uti

on

M

NP

Sea

rch

fo

r d

ang

er s

ign

s an

d r

efer

ral

EC

D17

Ch

ild

pro

tect

ion

BE

NIN

Cam

paig

ns

XX

BU

RK

INA

FA

SO

Cam

paig

ns a

nd r

outin

eX

XX

X

CA

ME

RO

ON

Cam

paig

nsX

XX

CA

RC

ampa

igns

XX

CH

AD

C

ampa

igns

and

rou

tine

XX

XX

XX

CO

NG

OC

ampa

igns

and

rou

tine

XX

X

CÔ

TE D

’IVO

IRE

Cam

paig

nsX

XX

X

DR

CC

ampa

igns

XX

XX

X

GA

MB

IA, T

HE

Cam

paig

ns a

nd r

outin

e X

XX

XX

X

GH

AN

AX

X

GU

INE

AC

ampa

igns

and

rou

tine

XX

XX

X

GU

INE

A B

ISS

AU

Cam

paig

nsX

XX

LIB

ER

IAC

ampa

igns

XX

X

MA

LIC

ampa

igns

XX

X

MA

UR

ITA

NIA

Cam

paig

nsX

XX

X

NIG

ER

Cam

paig

nsX

X

NIG

ER

IA

Cam

paig

nsX

XX

XX

SE

NE

GA

LC

ampa

igns

and

rou

tine

XX

XX

XX

SIE

RR

A L

EO

NE

XX

XX

X

TOG

O

Cam

paig

ns a

nd r

outin

e X

XX

16. I

n 11

cou

ntrie

s pr

ovis

ion

of v

itam

in A

and

alb

enda

zole

/meb

enda

zole

is c

arrie

d ou

t du

ring

cam

paig

ns, a

nd in

7 c

ount

ries

both

dur

ing

cam

paig

ns a

nd r

outin

ely.

Sie

rra

Leon

e di

d no

t sp

ecify

the

pr

ovis

ion

patt

erns

. 17

. EC

D a

s pa

rt o

f th

e pr

even

tion

activ

ities

is d

efine

d as

an

activ

e pa

rtic

ipat

ion

of C

HW

s th

roug

h ga

mes

, son

gs, m

assa

ges,

etc

.



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Chi

ldho

od il

lnes

ses

(und

er 5

) / iC

CM

- C

urat

ive

care

CO

UN

TRY

Feve

r (p

arac

etam

ol)

Dia

rrh

ea (

OR

S a

nd

Zn

)P

neu

mo

nia

(a

mo

xici

llin

)M

alar

ia (

RD

T a

nd

AC

T)

Sev

ere

acu

te

mal

nu

trit

ion

(a

mo

xici

llin

an

d R

UT

F)

BE

NIN

XX

XX

BU

RK

INA

FA

SO

XX

XX

CA

ME

RO

ON

XX

XX

CA

RX

XX

X

CH

AD

X

XX

XX

CO

NG

OX

XX

X

CÔ

TE D

’IVO

IRE

XX

XX

DR

CX

XX

X

GA

MB

IA, T

HE

XX

XX

X

GH

AN

AX

XX

XX

GU

INE

AX

XX

XX

GU

INE

A B

ISS

AU

XX

XX

LIB

ER

IAX

XX

X

MA

LIX

XX

XX

MA

UR

ITA

NIA

XX

XX

NIG

ER

XX

XX

NIG

ER

IA

XX

XX

X

SE

NE

GA

LX

XX

X

SIE

RR

A L

EO

NE

XX

XX

TOG

O

XX

XX

X



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Ado

lesc

ent

CO

UN

TRY

Pre

ven

tio

n

of

teen

age

pre

gn

anci

es

Men

stru

al

hyg

ien

e P

reve

nti

on

of

child

mar

riag

e H

PV

vac

cin

eIr

on

/fo

lic a

cid

N

utr

itio

nal

ed

uca

tio

n

HIV

pre

ven

tio

n

BE

NIN

--

--

--

-

BU

RK

INA

FA

SO

--

--

--

-

CA

ME

RO

ON

X

CA

R-

--

--

--

CH

AD

X

XX

XX

XX

CO

NG

OX

CÔ

TE D

’IVO

IRE

XX

DR

CX

XX

XX

X

GA

MB

IA, T

HE

XX

XX

(onl

y in

one

re

gion

)X

XX

GH

AN

A-

--

--

--

GU

INE

AX

XX

XX

X

GU

INE

A B

ISS

AU

--

--

--

-

LIB

ER

IAX

X

MA

LIX

X

MA

UR

ITA

NIA

--

--

--

-

NIG

ER

--

--

--

-

NIG

ER

IA

X

SE

NE

GA

LX

XX

XX

XX

SIE

RR

A L

EO

NE

XX

TOG

O

--

--

--

-



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Fam

ily p

lann

ing

CO

UN

TRY

P

rom

oti

on

C

ou

nse

ling

an

d

refe

rral

P

rovi

sio

n o

f co

nd

om

s P

rovi

sio

n o

f p

illP

rovi

sio

n o

f in

ject

able

BE

NIN

XX

BU

RK

INA

FA

SO

XX

XR

efill

Con

tinua

tion

CA

ME

RO

ON

XX

X

CA

RX

XX

Refi

ll

CH

AD

X

XX

Initi

al o

ffer

and

refi

llIn

itiat

ion

and

cont

inua

tion

CO

NG

OX

XX

CÔ

TE D

’IVO

IRE

XX

XR

efill

DR

CX

XX

Refi

ll

GA

MB

IA, T

HE

XX

XIn

itial

off

er a

nd r

efill

Initi

atio

n an

d co

ntin

uatio

n

GH

AN

AX

XX

Initi

al o

ffer

and

refi

ll

GU

INE

AX

XX

Initi

al o

ffer

and

refi

llIn

itiat

ion

and

cont

inua

tion

GU

INE

A B

ISS

AU

XX

XIn

itial

off

er a

nd r

efill

LIB

ER

IAX

XX

Refi

ll

MA

LIX

XX

Initi

al o

ffer

and

refi

llIn

itiat

ion

and

cont

inua

tion

MA

UR

ITA

NIA

XX

NIG

ER

--

--

-

NIG

ER

IA

XX

XIn

itial

off

er a

nd r

efill

SE

NE

GA

LX

XX

Initi

al o

ffer

and

refi

ll In

itiat

ion

and

cont

inua

tion

SIE

RR

A L

EO

NE

XX

Refi

ll

TOG

O

XX

XIn

itial

off

er a

nd r

efill

Initi

atio

n an

d co

ntin

uatio

n



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

HIV

CO

UN

TRY

E

du

cati

on

an

d p

reve

nti

on

Co

un

selin

g f

or

trea

tmen

t ad

her

ence

Aw

aren

ess

of

stig

ma

and

d

iscr

imin

atio

ns

BE

NIN

X

BU

RK

INA

FA

SO

XX

CA

ME

RO

ON

XX

X

CA

RX

CH

AD

X

XX

CO

NG

OX

CÔ

TE D

’IVO

IRE

XX

X

DR

CX

XX

GA

MB

IA, T

HE

XX

X

GH

AN

AX

GU

INE

AX

XX

GU

INE

A B

ISS

AU

XX

X

LIB

ER

IAX

X

MA

LIX

XX

MA

UR

ITA

NIA

X

NIG

ER

--

-

NIG

ER

IA

XX

X

SE

NE

GA

LX

XX

SIE

RR

A L

EO

NE

X

TOG

O

--

-



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Tube

rcul

osis

CO

UN

TRY

Ed

uca

tio

n o

f co

mm

un

ity

Ho

me

visi

ts

Det

ecti

on

an

d

ori

enta

tio

n o

f su

spec

t ca

ses

Sea

rch

an

d

ori

enta

tio

n o

f p

osi

tive

cas

es

con

tact

s

Dir

ectl

y O

bse

rved

Tr

eatm

ent

(DO

T)

Follo

w-u

p

of

con

tro

l ap

po

intm

ents

BE

NIN

XX

X

BU

RK

INA

FA

SO

XX

XX

CA

ME

RO

ON

XX

XX

CA

R-

--

--

-

CH

AD

X

XX

XX

X

CO

NG

O-

--

--

-

CÔ

TE D

’IVO

IRE

XX

XX

XX

DR

CX

XX

XX

GA

MB

IA, T

HE

XX

XX

XX

GH

AN

A

GU

INE

AX

XX

XX

X

GU

INE

A B

ISS

AU

XX

XX

LIB

ER

IAX

XX

XX

X

MA

LI-

--

--

-

MA

UR

ITA

NIA

XX

X

NIG

ER

--

--

--

NIG

ER

IA

XX

XX

X

SE

NE

GA

LX

XX

XX

X

SIE

RR

A L

EO

NE

X

TOG

O

XX

XX

XX



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Com

mun

ity-b

ased

sur

veill

ance

/ P

art

1

CO

UN

TRY

MU

AC

sc

reen

ing

an

d

refe

rral

Ch

ole

raM

enin

git

isH

emo

rrh

agic

fe

vers

, in

cl.

EB

V

Mea

sles

Po

lioYe

llow

fev

er

BE

NIN

XX

X

BU

RK

INA

FA

SO

XX

XX

XX

CA

ME

RO

ON

X

CA

RX

XX

X

CH

AD

X

XX

XX

CO

NG

OX

X

CÔ

TE D

’IVO

IRE

XX

XX

XX

X

DR

CX

XX

XX

X

GA

MB

IA, T

HE

XX

XX

XX

X

GH

AN

AX

XX

XX

GU

INE

AX

XX

XX

XX

GU

INE

A B

ISS

AU

XX

XX

X

LIB

ER

IAX

XX

XX

XX

MA

LIX

MA

UR

ITA

NIA

XX

XX

XX

X

NIG

ER

X

NIG

ER

IA

XX

XX

XX

X

SE

NE

GA

LX

XX

XX

XX

SIE

RR

A L

EO

NE

XX

XX

XX

X

TOG

O

XX

XX

XX

X



AN

NE

X C

.4 -

PAC

KA

GE

OF

SE

RV

ICE

S

4.2

Com

posi

tion

of C

HW

s pa

ckag

e of

ser

vice

s fo

r ea

ch c

ateg

ory

of s

ervi

ces

Com

mun

ity-b

ased

sur

veill

ance

/ P

art

2

CO

UN

TRY

N

eon

atal

te

tan

us

Gu

inea

wo

rmLe

pro

sy

Mat

ern

al

dea

ths

Neo

nat

al

dea

ths

Clu

ster

ed

dea

ths

An

y su

spic

iou

s ca

se

BE

NIN

X

BU

RK

INA

FA

SO

XX

XX

(3/7

0 di

stric

ts)

X (3

/70

dist

ricts

)

CA

ME

RO

ON

XX

X

CA

RX

X

CH

AD

X

XX

XX

X

CO

NG

OX

X

CÔ

TE D

’IVO

IRE

XX

XX

XX

DR

CX

XX

XX

GA

MB

IA, T

HE

XX

XX

XX

GH

AN

AX

XX

XX

XX

GU

INE

AX

XX

XX

XX

GU

INE

A B

ISS

AU

X

LIB

ER

IAX

XX

XX

MA

LIX

XX

X

MA

UR

ITA

NIA

XX

XX

XX

NIG

ER

XX

NIG

ER

IA

XX

XX

XX

X

SE

NE

GA

LX

XX

XX

XX

SIE

RR

A L

EO

NE

XX

XX

XX

TOG

O

XX

XX

XX

X



AN

NE

X C

.5 -

SU

PP

LY M

AN

AG

EM

EN

T

CO

UN

TRY

Pro

cure

men

t p

lan

C

om

mu

nit

y p

rocu

rem

ent

for

med

icin

es

and

eq

uip

men

t in

teg

rate

d in

to t

he

nat

ion

al s

up

ply

sys

tem

Sys

tem

in p

lace

co

nsi

der

ed t

o b

e ef

fect

ive

BE

NIN

Yes

No

No

BU

RK

INA

FA

SO

Yes

Yes

No

CA

ME

RO

ON

No

Yes

No

CA

RN

oN

oN

o

CH

AD

Ye

sYe

sN

o

CO

NG

ON

oN

oN

o

CÔ

TE D

’IVO

IRE

Yes

Yes

No

DR

CYe

sYe

sYe

s

GA

MB

IA, T

HE

Yes

Yes

No

GH

AN

AYe

sYe

sYe

s

GU

INE

AYe

sYe

sYe

s

GU

INE

A B

ISS

AU

No

No

No

LIB

ER

IAYe

sYe

sN

o

MA

LIYe

sYe

sYe

s18

MA

UR

ITA

NIA

Yes

Yes

No

NIG

ER

Yes

Yes

Yes

NIG

ER

IA

No

No

No

SE

NE

GA

LYe

sYe

sN

o

SIE

RR

A L

EO

NE

Yes

Yes

No

TOG

O

Yes

No

No

18. T

he s

yste

m is

con

side

red

to b

e ef

fect

ive

only

for

the

com

mer

cial

sec

tor,

thou

gh.



AN

NE

X C

.6 -

SE

RV

ICE

DE

LIV

ER

Y A

ND

RE

FER

RA

L

CO

UN

TRY

Ref

eren

ce t

o a

pp

rop

riat

e to

ols

fo

r cl

inic

al a

sses

smen

t,

dia

gn

osi

s, m

anag

emen

t an

d

refe

rral

Co

mm

un

ity

hea

lth

ref

erra

l p

roce

du

re

Co

un

ter-

refe

rral

mec

han

ism

R

efer

ral c

ases

rep

ort

s in

C

HW

s re

po

rts

BE

NIN

Yes

Writ

ten,

Acc

ompa

nyin

g Ye

sYe

s

BU

RK

INA

FA

SO

Yes

Writ

ten,

Acc

ompa

nyin

gYe

sYe

s

CA

ME

RO

ON

Yes

Writ

ten,

Acc

ompa

nyin

gYe

sYe

s

CA

RYe

sW

ritte

n, A

ccom

pany

ing

Yes

Yes

CH

AD

Ye

sVe

rbal

, Writ

ten,

A

ccom

pany

ing

No

Yes

CO

NG

OYe

sW

ritte

nYe

sYe

s

CÔ

TE D

’IVO

IRE

Yes

Verb

al, W

ritte

n,

Acc

ompa

nyin

gYe

sYe

s

DR

CYe

sW

ritte

nYe

sYe

s

GA

MB

IA, T

HE

Yes

Verb

al, A

ccom

pany

ing

Yes

Yes

GH

AN

AYe

sW

ritte

nYe

sYe

s

GU

INE

AYe

sW

ritte

n, A

ccom

pany

ing

Yes

Yes

GU

INE

A B

ISS

AU

Yes

Writ

ten,

Acc

ompa

nyin

gYe

sYe

s

LIB

ER

IAYe

sVe

rbal

, Writ

ten,

A

ccom

pany

ing

Yes

Yes

MA

LIYe

sW

ritte

nYe

sYe

s

MA

UR

ITA

NIA

Yes

Verb

al, W

ritte

n,

Acc

ompa

nyin

gN

oYe

s

NIG

ER

Yes

Verb

al, W

ritte

n,

Acc

ompa

nyin

gYe

sYe

s

NIG

ER

IA

No

Writ

ten

No

Yes

SE

NE

GA

LYe

sW

ritte

n, A

ccom

pany

ing

No

Yes

SIE

RR

A L

EO

NE

Yes

Writ

ten,

Acc

ompa

nyin

gYe

sYe

s

TOG

O

Yes

Verb

al, W

ritte

n,

Acc

ompa

nyin

gYe

sYe

s




AN

NE

X C

.7 -

CO

MM

UN

ITY

EN

GA

GE

ME

NT

CO

UN

TRY

Str

ateg

y fo

r co

mm

un

ity

eng

agem

ent

Acc

ou

nta

bili

ty

fram

ewo

rk

Ab

ility

to

tak

e le

ader

ship

in

hea

lth

issu

es

Ab

ility

to

get

in

volv

ed in

p

lan

nin

g, M

&E

of

inte

rven

tio

ns

Ab

ility

to

so

lve

pro

ble

ms

at lo

cal

leve

l

Ab

ility

to

mo

bili

ze

reso

urc

es

BE

NIN

Yes

Yes

Yes

Yes

Yes

Yes

BU

RK

INA

FA

SO

Yes

Yes

Yes

Yes

Yes

Yes

CA

ME

RO

ON

No

Yes19

No

Yes

Yes

Yes

CA

RYe

sN

oYe

sYe

sYe

sYe

s

CH

AD

Ye

sN

oYe

sYe

sYe

sYe

s

CO

NG

OYe

sN

oYe

sYe

sYe

sN

o

CÔ

TE D

’IVO

IRE

Yes

Yes

Yes

Yes

Yes

Yes

DR

CYe

sYe

sYe

sYe

sYe

sYe

s

GA

MB

IA, T

HE

Yes

Yes

Yes

Yes

Yes

Yes

GH

AN

AYe

sYe

sYe

sYe

sYe

sYe

s

GU

INE

AYe

sYe

sYe

sYe

sYe

sYe

s

GU

INE

A B

ISS

AU

No

No

No

No

No

No

LIB

ER

IAYe

sYe

sYe

sYe

sYe

sYe

s

MA

LIYe

sN

oYe

sYe

sYe

sYe

s

MA

UR

ITA

NIA

Yes

Yes

Yes

Yes

Yes

Yes

NIG

ER

Yes

Yes

Yes

Yes

Yes

Yes

NIG

ER

IA

No

No

No

No

Yes

No

SE

NE

GA

LYe

sYe

sYe

sYe

sYe

sYe

s

SIE

RR

A L

EO

NE

Yes

No

Yes

Yes

Yes

No

TOG

O

No

No

Yes

Yes

Yes

No

19. H

owev

er, t

he s

yste

m is

con

side

red

to b

e no

n-fu

nctio

nal


AN

NE

X C

.8 -

SU

PE

RV

ISIO

N A

ND

PE

RFO

RM

AN

CE

QU

ALI

TY A

SS

UR

AN

CE

CO

UN

TRY

Su

per

visi

on

pla

n

Su

per

viso

rs /

sup

ervi

sees

rat

ioTi

me

ded

icat

ed t

o

sup

ervi

sors

tra

inin

g

Ad

equ

ate

reso

urc

es

avai

lab

le f

or

app

rop

riat

e su

per

visi

on

Freq

uen

cy o

f re

po

rt

sub

mis

sio

n

BE

NIN

Yes

1/12

1 da

yYe

sM

onth

ly

BU

RK

INA

FA

SO

Yes

Inde

term

inat

e N

o tr

aini

ngYe

sM

onth

ly

CA

ME

RO

ON

Yes

1/8

Trai

ning

mod

ule

unde

r de

velo

pmen

t N

oM

onth

ly

CA

RYe

s8/

1511

day

sYe

sM

onth

ly

CH

AD

Ye

sIn

dete

rmin

ate

2 to

5 d

ays

Yes

Mon

thly

CO

NG

OYe

s1/

57

days

No

Mon

thly

CÔ

TE D

’IVO

IRE

Yes

1/10

6 da

ysYe

sM

onth

ly &

qua

rter

ly

DR

CYe

s1/

area

7

days

Yes

Mon

thly

GA

MB

IA, T

HE

Yes

1/5

to 1

/9 v

illag

es24

mon

ths

Yes

Mon

thly

GH

AN

AYe

s1/

2 to

1/1

0

Yes

Mon

thly

GU

INE

AYe

s1/

1011

day

sYe

sM

onth

ly

GU

INE

A B

ISS

AU

Yes

1/45

7 da

ys

Yes

Mon

thly

LIB

ER

IAYe

s1/

1025

day

sYe

sM

onth

ly

MA

LIYe

s1

team

of

supe

rvis

ors

per

10 t

o 20

CH

Ws

7 da

ysYe

sM

onth

ly

MA

UR

ITA

NIA

Yes

1/5

5 da

ysYe

sE

very

45

days

NIG

ER

Yes

1/5

7 da

ysYe

sM

onth

ly

NIG

ER

IA

Yes

Inde

term

inat

e 14

day

sN

oW

eekl

y

SE

NE

GA

LYe

sIn

dete

rmin

ate

5 da

ysYe

sM

onth

ly

SIE

RR

A L

EO

NE

Yes

1/10

3 m

onth

s Ye

sM

onth

ly

TOG

O

Yes

1/5

(hea

lth f

acili

ty

man

ager

)1/

20 (v

olun

teer

su

perv

isor

)

10 d

ays

Yes

Mon

thly




AN

NE

X C

.9 -

MO

NIT

OR

ING

AN

D E

VALU

ATI

ON

, AN

D C

OM

MU

NIT

Y H

EA

LTH

INFO

RM

ATI

ON

SY

STE

MS

CO

UN

TRY

Co

mp

reh

ensi

ve m

on

ito

rin

g f

ram

ewo

rk

and

sys

tem

In

teg

rati

on

of

com

mu

nit

y h

ealt

h d

ata

wit

hin

th

e n

atio

nal

hea

lth

info

rmat

ion

sy

stem

Dig

ital

izat

ion

of

com

mu

nit

y h

ealt

h d

ata

BE

NIN

Yes

Yes

No

BU

RK

INA

FA

SO

Yes

Yes

Yes

CA

ME

RO

ON

In p

rogr

ess

No

No

CA

RYe

sN

oN

o

CH

AD

N

oN

oN

o

CO

NG

ON

oYe

sN

o

CÔ

TE D

’IVO

IRE

No

Yes

No

DR

CYe

sYe

sN

o

GA

MB

IA, T

HE

Yes

Yes

Yes

GH

AN

AYe

sYe

sYe

s

GU

INE

AYe

sN

oN

o

GU

INE

A B

ISS

AU

Yes

No

Yes

LIB

ER

IAYe

sYe

sYe

s

MA

LIYe

sYe

sN

o

MA

UR

ITA

NIA

No

No

No

NIG

ER

Yes

Yes

No

NIG

ER

IA

Yes

Yes

Yes

SE

NE

GA

LYe

sYe

sYe

s

SIE

RR

A L

EO

NE

Yes

Yes

Yes

TOG

O

Yes

Yes

No


ANNEX DQuestionnaire

CO

OR

DIN

ATI

ON

AN

D P

OLI

TIC

AL

EN

VIR

ON

ME

NT

1

Coo

rdin

atio

n an

d po

litic

al e

nviro

nmen

t

1.

Whi

ch o

ffic

ial d

ocum

ents

gu

ide

the

com

mun

ity

heal

th p

rogr

am?

If a

pplic

able

, ple

ase

spec

ify d

ate

and

nam

e of

con

cern

ed

docu

men

ts.

M

ultip

le r

espo

nses

allo

wed

.

□ P

olic

y

□ S

trat

egic

pla

n

□ A

ctio

n pl

an

□ G

uide

lines

□

Oth

er –

Ple

ase

spec

ify:

Ple

ase

indi

cate

whe

ther

a n

ew d

ocum

ent

is b

eing

dev

elop

ed:

If a

com

mun

ity h

ealth

pol

icy

does

not

exi

st, p

leas

e sp

ecify

whi

ch o

ther

nat

iona

l pol

icy

refe

rs t

o co

mm

unity

hea

lth:

2.

In y

our

opin

ion,

do

the

com

mun

ity h

ealth

pol

icy

and/

or s

trat

egy

resp

ond

to t

he f

ollo

win

g ke

y pr

inci

ples

?

Eq

uit

y

□ P

rinci

ple

is n

ot m

entio

ned

in p

olic

y do

cum

ents

□

Prin

cipl

e is

men

tione

d bu

t no

t cl

early

spe

cifie

d

□

Prin

cipl

e is

men

tione

d an

d cl

early

spe

cifie

d

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Gen

der

eq

ual

ity

□ P

rinci

ple

is n

ot m

entio

ned

in p

olic

y do

cum

ents

□

Prin

cipl

e is

men

tione

d bu

t no

t cl

early

spe

cifie

d

□

Prin

cipl

e is

men

tione

d an

d cl

early

spe

cifie

d

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Co

mm

un

ity

eng

agem

ent

□ P

rinci

ple

is n

ot m

entio

ned

in p

olic

y do

cum

ents

□

Prin

cipl

e is

men

tione

d bu

t no

t cl

early

spe

cifie

d

□

Prin

cipl

e is

men

tione

d an

d cl

early

spe

cifie

d

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Loca

l go

vern

ance

□

Prin

cipl

e is

not

men

tione

d in

pol

icy

docu

men

ts

□ P

rinci

ple

is m

entio

ned

but

not

clea

rly s

peci

fied

□ P

rinci

ple

is m

entio

ned

and

clea

rly s

peci

fied

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs



CO

OR

DIN

ATI

ON

AN

D P

OLI

TIC

AL

EN

VIR

ON

ME

NT

2

Acc

ou

nta

bili

ty

□ P

rinci

ple

is n

ot m

entio

ned

in p

olic

y do

cum

ents

□

Prin

cipl

e is

men

tione

d bu

t no

t cl

early

spe

cifie

d

□ P

rinci

ple

is m

entio

ned

and

clea

rly s

peci

fied

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Su

stai

nab

ility

□

Prin

cipl

e is

not

men

tione

d in

pol

icy

docu

men

ts

□ P

rinci

ple

is m

entio

ned

but

not

clea

rly s

peci

fied

□ P

rinci

ple

is m

entio

ned

and

clea

rly s

peci

fied

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Mu

ltis

ecto

rial

ity

□ P

rinci

ple

is n

ot m

entio

ned

in p

olic

y do

cum

ents

□

Prin

cipl

e is

men

tione

d bu

t no

t cl

early

spe

cifie

d

□ P

rinci

ple

is m

entio

ned

and

clea

rly s

peci

fied

□ P

rogr

ess

is m

onito

red

thro

ugh

indi

cato

rs

Co

mm

ents

:

3.

Is t

he

polic

y/st

rate

gy/g

uide

line

base

d on

a s

ituat

iona

l an

alys

is a

nd n

eeds

as

sess

men

t?

Mul

tiple

res

pons

es a

llow

ed

□ Y

es

□ N

o If

yes

, ple

ase

spec

ify:

a)

The

year

of

the

situ

atio

nal a

naly

sis:

-----

------

------

------

---

b)

w

heth

er t

he a

naly

sis

is b

ased

on

:

□ A

des

k re

view

□

A m

appi

ng –

Ple

ase

spec

ify (p

opul

atio

ns, a

ctiv

ities

, CH

Ws,

par

tner

s):

□ A

n ev

alua

tion

of t

he p

rogr

am

□ A

n ex

pert

s co

nsul

tatio

n

□

Oth

er –

Ple

ase

spec

ify:



CO

OR

DIN

ATI

ON

AN

D P

OLI

TIC

AL

EN

VIR

ON

ME

NT

3

4.

Wha

t of

ficia

l doc

umen

ts

allo

w f

or t

reat

men

t at

co

mm

unity

leve

l for

the

fo

llow

ing

dise

ases

, if

appl

icab

le?

- D

iarr

hea

(OR

S/Z

n)?

-

Mal

aria

(RD

T an

d A

CT)

?

- P

neum

onia

(am

oxic

illin

)?

- S

ever

e A

cute

Mal

nutr

ition

(am

oxic

illin

and

Rea

dy-to

-Use

The

rape

utic

Foo

d)?

- C

ord

care

(chl

orhe

xidi

ne)?

- Fa

mily

Pla

nnin

g (c

ontr

acep

tives

, inc

ludi

ng in

ject

able

)?

-

Oth

er –

Ple

ase

spec

ify:

5.

Is

the

re a

nat

iona

l co

ordi

natin

g st

ruct

ure

for

com

mun

ity h

ealth

?

□ Y

es

□ N

o If

so,

a)

Wha

t is

the

sta

tus

and

nam

e of

thi

s st

ruct

ure?

□

Dire

ctio

n ---

------

------

------

------

------

--

□

Div

isio

n ---

------

------

------

------

------

--

□ C

omm

ittee

---

------

------

------

------

------

--

□ O

ther

– P

leas

e sp

ecify

: ----

------

------

-----

b)

P

leas

e sp

ecify

to

whi

ch b

ody

this

str

uctu

re is

dire

ctly

att

ache

d (e

.g. G

ener

al

Dire

ctor

ate

of H

ealth

, Dire

ctor

ate

of H

ealth

Pro

mot

ion,

etc

.):

6.

Is

the

re a

m

ultid

isci

plin

ary

natio

nal

com

mun

ity h

ealth

co

mm

ittee

?

M

ultip

le r

espo

nses

allo

wed

□ Y

es

□ N

o If

so,

ple

ase

spec

ify:

a)

The

inst

itutio

nal a

ncho

rage

of

this

com

mitt

ee (T

o w

hom

doe

s th

e co

mm

ittee

re

port

?):

b)

Th

e m

ain

role

of

this

com

mitt

ee:

□ D

ecis

ion

mak

ing

□ P

rogr

am m

onito

ring

□ P

latf

orm

for

exc

hang

e

□ O

ther

– P

leas

e sp

ecify

: C

omm

ents

:

3

4.

Wha

t of

ficia

l doc

umen

ts

allo

w f

or t

reat

men

t at

co

mm

unity

leve

l for

the

fo

llow

ing

dise

ases

, if

appl

icab

le?

- D

iarr

hea

(OR

S/Z

n)?

-

Mal

aria

(RD

T an

d A

CT)

?

- P

neum

onia

(am

oxic

illin

)?

- S

ever

e A

cute

Mal

nutr

ition

(am

oxic

illin

and

Rea

dy-to

-Use

The

rape

utic

Foo

d)?

- C

ord

care

(chl

orhe

xidi

ne)?

- Fa

mily

Pla

nnin

g (c

ontr

acep

tives

, inc

ludi

ng in

ject

able

)?

-

Oth

er –

Ple

ase

spec

ify:

5.

Is

the

re a

nat

iona

l co

ordi

natin

g st

ruct

ure

for

com

mun

ity h

ealth

?

□ Y

es

□ N

o If

so,

a)

Wha

t is

the

sta

tus

and

nam

e of

thi

s st

ruct

ure?

□

Dire

ctio

n ---

------

------

------

------

------

--

□

Div

isio

n ---

------

------

------

------

------

--

□ C

omm

ittee

---

------

------

------

------

------

--

□ O

ther

– P

leas

e sp

ecify

: ----

------

------

-----

b)

P

leas

e sp

ecify

to

whi

ch b

ody

this

str

uctu

re is

dire

ctly

att

ache

d (e

.g. G

ener

al

Dire

ctor

ate

of H

ealth

, Dire

ctor

ate

of H

ealth

Pro

mot

ion,

etc

.):

6.

Is

the

re a

m

ultid

isci

plin

ary

natio

nal

com

mun

ity h

ealth

co

mm

ittee

?

M

ultip

le r

espo

nses

allo

wed

□ Y

es

□ N

o If

so,

ple

ase

spec

ify:

a)

The

inst

itutio

nal a

ncho

rage

of

this

com

mitt

ee (T

o w

hom

doe

s th

e co

mm

ittee

re

port

?):

b)

Th

e m

ain

role

of

this

com

mitt

ee:

□ D

ecis

ion

mak

ing

□ P

rogr

am m

onito

ring

□ P

latf

orm

for

exc

hang

e

□ O

ther

– P

leas

e sp

ecify

: C

omm

ents

:



CO

OR

DIN

ATI

ON

AN

D P

OLI

TIC

AL

EN

VIR

ON

ME

NT

4

Ple

ase

tick

the

boxe

s co

rres

pond

ing

to t

he a

ppro

pria

te

answ

ers,

and

spe

cify

bod

y in

volv

ed in

eac

h ca

tego

ry.

c)

How

oft

en s

houl

d th

is c

omm

ittee

mee

t?

□ on

ce a

mon

th

□ ev

ery

6 m

onth

s

□

once

a y

ear

□

Oth

er –

Ple

ase

spec

ify:

d)

A

re t

he m

eetin

gs o

pera

tiona

l?

□ Y

es

□ N

o

e)

Wha

t is

the

com

posi

tion

of t

his

com

mitt

ee (o

r, if

suc

h a

com

mitt

ee d

oes

not

exis

t, w

hat

stru

ctur

es a

re in

volv

ed in

to t

he n

atio

nal c

omm

unity

hea

lth

orga

niza

tion)

?

□

Dire

ctio

ns, d

ivis

ions

, and

ser

vice

s of

the

Min

istr

y of

Hea

lth

□ O

ther

min

istr

ies

□ Te

chni

cal a

nd F

inan

cial

Par

tner

s

□ R

epre

sent

ativ

es o

f th

e pr

ivat

e se

ctor

□

Res

earc

h in

stitu

tes

□ O

ther

– P

leas

e sp

ecify

:

7.

W

hat

is t

he p

olic

y vi

sion

re

gard

ing

com

mun

ity

heal

th p

rogr

am

cove

rage

?

Cur

rent

cov

erag

e, in

ter

ms

of p

opul

atio

n, o

f th

e co

mm

unity

hea

lth p

rogr

am:

Pop

ulat

ion

plan

ned

to b

e co

vere

d at

the

pol

icy

com

plet

ion

date

:

8.

Doe

s a

plan

/str

ateg

y fo

r co

mm

unic

atio

n an

d so

cial

mob

iliza

tion

in

com

mun

ity h

ealth

exi

st

(or

a co

mm

unic

atio

n pl

an

for

Mat

erna

l, N

eona

tal

and

Chi

ld H

ealth

tha

t w

ould

incl

ude

a co

mm

unity

hea

lth

com

pone

nt)?

□ Y

es

□ N

o C

omm

ents

:



CO

STI

NG

AN

D F

INA

NC

ING

5

Cos

ting

and

finan

cing

9.

Are

the

cos

ts o

f th

e pr

ogra

m e

stim

ated

?

□

Yes

□

No

If s

o, p

leas

e sp

ecify

: ----

------

------

------

---- (

amou

nt) f

or --

------

---- y

ears

10.

Is f

inan

cing

sec

ured

by

a p

lan?

□

Yes

□

No

11

. Is

the

re a

nat

iona

l bu

dget

line

for

co

mm

unity

hea

lth?

□ Y

es

□

No

If s

o, a)

Wha

t w

as t

he a

mou

nt a

lloca

ted

in 2

016?

-----

------

------

------

--

in 2

017?

-----

------

------

------

--

b)

Wha

t pe

rcen

tage

of

the

heal

th b

udge

t do

es t

his

repr

esen

t? --

------

------

------

%

c)

Is

the

re a

pla

n m

ade

by t

he G

over

nmen

t to

incr

ease

thi

s sh

are?

□

Yes

□

No

C

omm

ents

: 12

. W

hat

are

the

mai

n ex

tern

al d

onor

s fo

r th

e co

mm

unity

hea

lth

prog

ram

?

□ U

NIC

EF

□ W

HO

□ U

SA

ID

□ C

IDA

□

Glo

bal F

und

□ O

ther

– P

leas

e sp

ecify

:

13.

Are

the

con

sulta

tions

m

ade

by C

HW

s fr

ee

of c

harg

e?

□ Y

es

□ N

o

□

Onl

y so

me

serv

ices

are

fre

e. P

leas

e sp

ecify

:

14.

Are

the

med

icin

es

and

supp

lies

for

serv

ices

off

ered

by

CH

Ws

free

of

char

ge?

□ Y

es

□ N

o

□

Onl

y so

me

serv

ices

are

fre

e. P

leas

e sp

ecify

:


CO

STI

NG

AN

D F

INA

NC

ING

6

Hum

an r

esou

rces

15.

Are

the

re s

ever

al

type

s of

CH

Ws

iden

tifie

d in

the

na

tiona

l com

mun

ity

heal

th p

olic

y do

cum

ents

?

□ Y

es

□ N

o

If s

o, p

leas

e sp

ecify

:

16.

Are

the

re o

ther

typ

es

of w

orke

rs c

arry

ing

out

heal

th a

ctiv

ities

in

the

com

mun

ity?

□ Y

es

□ N

o

If s

o, p

leas

e sp

ecify

:

17.

Are

the

re C

HW

s “s

peci

aliz

ed”

to

man

age

spec

ific

dise

ases

?

□ Y

es

□ N

o

If s

o, p

leas

e sp

ecify

wha

t th

e sp

ecia

lizat

ions

are

:

18.

If m

ore

than

tw

o ty

pes

of C

HW

s ex

ist,

a)

P

leas

e sp

ecify

why

:

b)

Is t

his

mul

tiplic

ity e

ffec

tive

in y

our

cont

ext?

□

Yes

□

No

c)

Is

the

re a

n in

tent

ion

to s

impl

ify t

his

orga

niza

tiona

l sch

eme?

□

Yes

□

No

C

omm

ents

:

For

qu

esti

on

s 19

to

28,

ple

ase

answ

er f

ocu

sin

g o

n C

HW

(s)

ackn

ow

led

ged

(w

ho

se s

tatu

s is

cle

arly

def

ined

) in

th

e p

olic

y d

ocu

men

ts, o

r o

n t

he

two

typ

es t

hat

wo

uld

be

the

clo

sest

of

a fu

ture

inst

itu

tio

nal

izat

ion

. N

.B. I

n t

he

nex

t q

ues

tio

ns

“CH

Ws”

is u

sed

gen

eric

ally

an

d e

nco

mp

asse

s al

l typ

es o

f co

mm

un

ity

agen

ts. P

leas

e sp

ecif

y w

hic

h t

wo

typ

es o

f ag

ents

(C

HW

, ass

ista

nt,

rel

ay, v

olu

nte

er, e

tc.)

are

tak

en in

to a

cco

un

t in

yo

ur

con

text

.



HU

MA

N R

ES

OU

RC

ES

7

Typ

es o

f ag

ents

A

gent

1 :

------

------

------

------

------

------

------

------

Age

nt 2

: ---

------

------

------

------

------

------

------

--

19.

Wha

t is

the

CH

W

stat

us?

□

Civ

il se

rvan

t

□

Sta

te c

ontr

act

wor

ker

□

NG

O c

ontr

act

wor

ker

□

Sta

te v

olun

teer

□

NG

O v

olun

teer

□

Oth

er –

Ple

ase

spec

ify :

□ C

ivil

serv

ant

□ S

tate

con

trac

t w

orke

r

□

NG

O c

ontr

act

wor

ker

□ S

tate

vol

unte

er

□ N

GO

vol

unte

er

□ O

ther

– P

leas

e sp

ecify

: 20

. Is

the

CH

W

reco

gniz

ed b

y th

e P

ublic

Hea

lth

code

/law

?

□ Y

es

□

No

Com

men

ts :

□ Y

es

□ N

o C

omm

ents

:

21

. W

hat

are

the

mea

ns

of r

ecog

nitio

n of

C

HW

s?

□ C

ensu

s/m

appi

ng

□

at n

atio

nal l

evel

□ at

reg

iona

l lev

el

□

at lo

cal l

evel

□ O

ther

– P

leas

e sp

ecify

: If

suc

h a

map

ping

is a

vaila

ble,

how

man

y ag

ents

1

have

bee

n re

gist

ered

to

date

in t

he

coun

try?

□

Iden

tific

atio

n m

arks

□

jack

et/t

-shi

rt/c

ap

□

badg

e/ca

rd

□

atte

stat

ion

□ C

ontr

act

□ em

ploy

men

t co

ntra

ct o

f in

defin

ite

dura

tion

□

empl

oym

ent

cont

ract

of

limite

d

d

urat

ion

□

perf

orm

ance

con

trac

t If

suc

h a

cont

ract

is s

igne

d, p

leas

e sp

ecify

th

e st

akeh

olde

rs in

the

con

trac

t :

□ C

ensu

s/m

appi

ng

□

at n

atio

nal l

evel

□ at

reg

iona

l lev

el

□

at lo

cal l

evel

□ O

ther

– P

leas

e sp

ecify

: If

suc

h a

map

ping

is a

vaila

ble,

how

man

y ag

ents

2

have

bee

n re

gist

ered

to

date

in t

he

coun

try?

□

Iden

tific

atio

n m

arks

□

jack

et/t

-shi

rt/c

ap

□

badg

e/ca

rd

□ at

test

atio

n □

Con

trac

t

□ em

ploy

men

t co

ntra

ct o

f

ind

efin

ite d

urat

ion

□

empl

oym

ent

cont

ract

of

limite

d

dura

tion

□

perf

orm

ance

con

trac

t If

suc

h a

cont

ract

is s

igne

d, p

leas

e sp

ecify

th

e st

akeh

olde

rs in

the

con

trac

t :



HU

MA

N R

ES

OU

RC

ES

8

22.

How

muc

h tim

e do

es

a C

HW

hav

e to

de

dica

te t

o hi

s ac

tiviti

es?

------

------

------

hour

s pe

r w

eek

------

------

------

days

per

mon

ths

------

------

------

hour

s pe

r w

eek

---

------

------

---da

ys p

er m

onth

s

23.

Wha

t is

the

mod

e of

C

HW

s re

mun

erat

ion?

Ple

ase

spec

ify a

mou

nt a

nd/o

r up

per

limit

if ap

plic

able

and

the

so

urce

(Min

istr

y/N

GO

/etc

.) M

ultip

le r

espo

nses

allo

wed

□ S

alar

y □

PB

F

□ M

otiv

atio

n

□ S

pora

dic

per

diem

□ Fe

e fo

r se

rvic

e C

omm

ents

:

□ S

alar

y □

PB

F □

Mot

ivat

ion

□

Spo

radi

c pe

r di

em

□

Fee

for

serv

ice

Com

men

ts :

24

. Is

the

re a

str

ateg

y fo

r C

HW

s re

tent

ion?

M

ultip

le r

espo

nses

allo

wed

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

: □

Car

eer

path

way

s □

Invo

lvem

ent

in p

eer

trai

ning

□ B

enef

its in

the

com

mun

ity

□ E

xem

ptio

n fr

om f

ees

for

heal

thca

re

□ H

onor

ific

awar

ds

□ O

ther

– P

leas

e sp

ecify

:

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

: □

Car

eer

path

way

s □

Invo

lvem

ent

in p

eer

trai

ning

□ B

enef

its in

the

com

mun

ity

□ E

xem

ptio

n fr

om f

ees

for

heal

thca

re

□ H

onor

ific

awar

ds

□ O

ther

– P

leas

e sp

ecify

: 25

. W

hat

is t

he d

ensi

ty o

f C

HW

s (n

umbe

r of

C

HW

s pe

r in

habi

tant

/hou

seho

ld):

a)

Rec

omm

ende

d at

nat

iona

l lev

el?

b)

Eff

ectiv

e?

a)

Rec

omm

ende

d at

nat

iona

l lev

el?

b)

Eff

ectiv

e?

26.

Wha

t ed

ucat

iona

l lev

el

is r

equi

red?

□

Non

e □

Rea

ding

and

cal

cula

tion

□

Prim

ary

leve

l

□ S

econ

dary

leve

l

□ N

one

□ R

eadi

ng a

nd c

alcu

latio

n

□ P

rimar

y le

vel

□

Sec

onda

ry le

vel

27.

Reg

ardi

ng C

HW

s tr

aini

ng,

a)

Is

the

re a

pre

-ser

vice

tr

aini

ng p

lan?

□ Y

es

□

No

If s

o, p

leas

e:

- s p

ecify

the

dur

atio

n of

the

tra

inin

g:

- br

iefly

det

ail t

he m

ain

area

s co

vere

d:

□

Yes

□

No

If s

o, p

leas

e:

- s p

ecify

the

dur

atio

n of

the

tra

inin

g:

- br

iefly

det

ail t

he m

ain

area

s co

vere

d:


8

22.

How

muc

h tim

e do

es

a C

HW

hav

e to

de

dica

te t

o hi

s ac

tiviti

es?

------

------

------

hour

s pe

r w

eek

------

------

------

days

per

mon

ths

------

------

------

hour

s pe

r w

eek

---

------

------

---da

ys p

er m

onth

s

23.

Wha

t is

the

mod

e of

C

HW

s re

mun

erat

ion?

Ple

ase

spec

ify a

mou

nt a

nd/o

r up

per

limit

if ap

plic

able

and

the

so

urce

(Min

istr

y/N

GO

/etc

.) M

ultip

le r

espo

nses

allo

wed

□ S

alar

y □

PB

F

□ M

otiv

atio

n

□ S

pora

dic

per

diem

□ Fe

e fo

r se

rvic

e C

omm

ents

:

□ S

alar

y □

PB

F □

Mot

ivat

ion

□

Spo

radi

c pe

r di

em

□

Fee

for

serv

ice

Com

men

ts :

24

. Is

the

re a

str

ateg

y fo

r C

HW

s re

tent

ion?

M

ultip

le r

espo

nses

allo

wed

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

: □

Car

eer

path

way

s □

Invo

lvem

ent

in p

eer

trai

ning

□ B

enef

its in

the

com

mun

ity

□ E

xem

ptio

n fr

om f

ees

for

heal

thca

re

□ H

onor

ific

awar

ds

□ O

ther

– P

leas

e sp

ecify

:

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

: □

Car

eer

path

way

s □

Invo

lvem

ent

in p

eer

trai

ning

□ B

enef

its in

the

com

mun

ity

□ E

xem

ptio

n fr

om f

ees

for

heal

thca

re

□ H

onor

ific

awar

ds

□ O

ther

– P

leas

e sp

ecify

: 25

. W

hat

is t

he d

ensi

ty o

f C

HW

s (n

umbe

r of

C

HW

s pe

r in

habi

tant

/hou

seho

ld):

a)

Rec

omm

ende

d at

nat

iona

l lev

el?

b)

Eff

ectiv

e?

a)

Rec

omm

ende

d at

nat

iona

l lev

el?

b)

Eff

ectiv

e?

26.

Wha

t ed

ucat

iona

l lev

el

is r

equi

red?

□

Non

e □

Rea

ding

and

cal

cula

tion

□

Prim

ary

leve

l

□ S

econ

dary

leve

l

□ N

one

□ R

eadi

ng a

nd c

alcu

latio

n

□ P

rimar

y le

vel

□

Sec

onda

ry le

vel

27.

Reg

ardi

ng C

HW

s tr

aini

ng,

a)

Is

the

re a

pre

-ser

vice

tr

aini

ng p

lan?

□ Y

es

□

No

If s

o, p

leas

e:

- sp

ecify

the

dur

atio

n of

the

tra

inin

g:

- br

iefly

det

ail t

he m

ain

area

s co

vere

d:

□

Yes

□

No

If s

o, p

leas

e:

- sp

ecify

the

dur

atio

n of

the

tra

inin

g:

- br

iefly

det

ail t

he m

ain

area

s co

vere

d:


HU

MA

N R

ES

OU

RC

ES

9

b)

Is t

here

an

in-

serv

ice/

refr

eshe

r tr

aini

ng p

lan?

□

Yes

□ N

o If

so,

ple

ase

spec

ify t

he f

requ

ency

: □

Eve

ry --

------

--wee

ks

□ E

very

------

-----m

onth

s □

------

------

------

times

a y

ear

□ E

very

------

-----y

ears

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

the

fre

quen

cy:

□ E

very

-----

-----w

eeks

□ E

very

------

-----m

onth

s □

------

------

------

times

a y

ear

□ E

very

------

-----y

ears

28

. Is

the

ann

ual C

HW

s at

triti

on r

ate

know

n?

□ Y

es

□ N

o If

so,

ple

ase

spec

ify: -

------

------

------

------

---

□ Y

es

□

No

If s

o, p

leas

e sp

ecify

: ---

------

------

------

------

- 29

. A

bout

gen

der,

a)

Is t

he C

HW

s se

x ra

tio

know

n?

b)

Is

the

com

mun

ity

heal

th p

olic

y ge

nder

-re

spon

sive

? M

ultip

le r

espo

nses

allo

wed

c)

Has

a r

esea

rch

on

CH

Ws

gend

er

spec

ifics

bee

n co

nduc

ted

in t

he

coun

try

yet?

□

Yes

□

No

If s

o, p

leas

e sp

ecify

:

------

------

------

------

---

If t

he r

atio

is u

nbal

ance

d (e

xclu

sive

ly o

r pr

edom

inan

tly m

ale/

fem

ale)

, wha

t ar

e, in

you

r op

inio

n, t

he f

acto

rs t

hat

influ

ence

it?

In y

our

opin

ion,

wha

t ar

e th

e be

nefit

s fo

r m

ale

or f

emal

e C

HW

s in

you

r co

ntex

t?

□ Y

es

□ N

o If

so,

wha

t ar

e th

e fa

ctor

s (f

or e

xam

ple

linke

d to

CH

Ws

sele

ctio

n or

wor

k co

nditi

ons)

co

ntrib

utin

g to

thi

s?

□

Yes

□

No

If s

o, p

leas

e sp

ecify

(stu

dy r

efer

ence

and

inst

itutio

ns in

volv

ed in

the

res

earc

h):



HU

MA

N R

ES

OU

RC

ES

10

Pac

kage

of

serv

ices

30.

Abo

ut t

he p

acka

ge

of s

ervi

ces

prov

ided

by

CH

Ws

and

the

geog

raph

ical

co

vera

ge,

Mul

tiple

res

pons

es a

llow

ed

For

each

fol

low

ing

cate

gory

of

serv

ices

, -

Ple

ase

tick

the

box(

es) c

orre

spon

ding

to

the

serv

ices

to

be p

rovi

ded

by C

HW

s (a

s pe

r th

e po

licy

or o

ffic

ial d

ocum

ent

gove

rnin

g co

mm

unity

hea

lth)

- P

leas

e sp

ecify

the

cov

erag

e of

the

ser

vice

s N

.B.

Par

tial

ly im

ple

men

ted

: onl

y a

few

act

iviti

es o

f th

e pa

ckag

e ar

e im

plem

ente

d or

all

activ

ities

are

impl

emen

ted

but

only

in a

few

com

mun

ities

in t

he d

istr

ict

Fu

lly im

ple

men

ted

: all

activ

ities

of

the

pack

age

of s

ervi

ces

are

impl

emen

ted

in a

ll co

mm

uniti

es in

the

dis

tric

t A

s it

is a

ssum

ed t

hat

the

prom

otio

n of

EFP

is im

plem

ente

d in

all

com

mun

ities

, nex

t qu

estio

ns f

ocus

on

othe

r in

terv

entio

ns.

The

inte

rven

tions

pro

pose

d in

the

fol

low

ing

resp

onse

s ta

ke in

to a

ccou

nt W

HO

/UN

ICE

F re

com

men

datio

ns a

nd in

terv

entio

ns im

plem

ente

d in

som

e co

untr

ies.

If, i

n yo

ur c

onte

xt,

othe

r in

terv

entio

ns a

re im

plem

ente

d, p

leas

e sp

ecify

(for

exa

mpl

e, if

the

nat

iona

l re

com

men

datio

ns d

o no

t in

clud

e O

RS

and

Zin

c fo

r th

e tr

eatm

ent

of c

hild

hood

dia

rrhe

a,

plea

se m

entio

n it)

, or

add

any

othe

r in

terv

entio

n.

Tota

l num

ber

of d

istr

icts

in t

he c

ount

ry: -

------

------

------

------

------

---



PAC

KA

GE

OF

SE

RV

ICE

S

11

An

te n

atal

an

d n

ewb

orn

(28

day

s) c

are

□ P

rom

oti

on

□ P

rom

otio

n an

d re

fere

nce

for t

he 4

AN

C v

isits

□ Ir

on/F

olic

aci

d

□

LLIN

s us

e

□

PM

TCT/

EM

TCT

□ D

eliv

ery

with

ski

lled

birt

h at

tend

ant

□

Ski

n to

ski

n co

ntac

t

□ P

rom

otio

n of

Kan

garo

o M

othe

r C

are

met

hod

a

t co

mm

unity

leve

l

□ E

xclu

sive

and

ear

ly b

reas

tfee

ding

□

Pos

t-pa

rtum

con

trac

eptio

n

□

Birt

h re

gist

ratio

n

□ Im

mun

izat

ion

□ E

arly

Chi

ldho

od D

evel

opm

ent

(act

ive

pa

rtic

ipat

ion

of C

HW

thr

ough

gam

es,

so

ngs,

mas

sage

s, e

tc.)

□

Oth

er- P

leas

e sp

ecify

:

□ P

reve

nti

on

□

Sup

port

dur

ing

labo

r in

the

pre

senc

e of

a

ski

lled

birt

h at

tend

ant

□

Mis

opro

stol

adm

inis

trat

ion

to p

reve

nt p

ost

-par

tum

hem

orrh

age

□

Hom

e vi

sits

aft

er d

eliv

ery

(24h

-72h

-7d)

□

Cor

d ca

re

□

natu

ral d

ryin

g

□

usin

g ch

lorh

exid

ine

□

New

born

wei

ght

cont

rol

□

New

born

tem

pera

ture

con

trol

□ K

anga

roo

Mot

her

Car

e at

com

mun

ity le

vel

□

initi

atio

n

□

mai

nten

ance

□

Sea

rch

for

mot

her

and

new

born

dan

ger

si

gns

and

refe

rral

□ O

ther

– P

leas

e sp

ecify

:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts



PAC

KA

GE

OF

SE

RV

ICE

S

12

C

hild

ho

od

illn

esse

s/iC

CM

(u

nd

er f

ive)

□ P

rom

oti

on

□

Imm

uniz

atio

n

□ V

acci

natio

n re

cord

con

trol

□

Nut

ritio

nal e

duca

tion

□ E

xclu

sive

bre

astf

eedi

ng u

ntil

6

mon

ths

and

brea

stfe

edin

g un

til 2

□ Y

oung

chi

ld f

eedi

ng

□ LL

INs

use

□ E

arly

chi

ldho

od d

evel

opm

ent

(onl

y

pro

mot

iona

l act

ivity

)

□

Oth

er –

Ple

ase

spec

ify :

□ P

reve

nti

on

□ P

rovi

sion

of

vita

min

e

A

-alb

enda

zole

/meb

enda

zole

□

durin

g ca

mpa

igns

□ ro

utin

ely

□ G

row

th c

ontr

ol

□ M

UA

C s

cree

ning

and

ref

erra

l

□

Dis

trib

utio

n of

Mic

ronu

trie

nts

Pow

der

(MN

P)

□ S

earc

h fo

r da

nger

sig

ns a

nd r

efer

ral

□ E

arly

chi

ldho

od d

evel

opm

ent

(act

ive

par

ticip

atio

n of

CH

W)

□ C

hild

pro

tect

ion

□ O

ther

– P

leas

e sp

ecify

:

□ C

ura

tive

car

e

□ Fe

ver

man

agem

ent

(par

acet

amol

)

□

Dia

rrhe

a m

anag

emen

t (O

RS

and

Zn)

□ P

neum

onia

(am

oxic

illin

)

□

Mal

aria

(RD

T et

AC

T)

□ S

ever

e ac

ute

mal

nutr

ition

(a

mox

icill

in

a

nd R

UTF

)

□

Oth

er –

Ple

ase

spec

ify:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts



PAC

KA

GE

OF

SE

RV

ICE

S

13

A

do

lesc

ent

□ P

reve

ntio

n of

tee

nage

pre

gnan

cies

□ M

enst

rual

hyg

iene

□ P

reve

ntio

n of

chi

ld m

arria

ge

□

HP

V v

acci

ne

□ Ir

on/f

olic

aci

d

□

Nut

ritio

nal e

duca

tion

□

HIV

pre

vent

ion

□ O

ther

- Ple

ase

spec

ify :

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts

Fa

mily

Pla

nn

ing

□ P

rom

otio

n

□ C

ouns

elin

g an

d re

ferr

al

□ P

rovi

sion

of

cont

race

ptiv

es

□

cond

oms

□

pill

□ in

itial

off

er

□ re

fill

□

inje

ctab

le

□ in

itial

off

er

□ m

aint

enan

ce

□ O

ther

– P

leas

e sp

ecify

:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts

H

IV

□ E

duca

tion

and

prev

entio

n

□

Cou

nsel

ing

for

trea

tmen

t ad

here

nce

□

Aw

aren

ess

of s

tigm

a an

d di

scrim

inat

ions

□ O

ther

– P

leas

e sp

ecify

:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts



PAC

KA

GE

OF

SE

RV

ICE

S

14

T

ub

ercu

losi

s

□

Edu

catio

n of

com

mun

ity

□ H

ome

visi

ts

□ D

etec

tion

and

orie

ntat

ion

of s

uspe

ct c

ases

□

Sea

rch

and

orie

ntat

ion

of p

ositi

ve c

ases

con

tact

s

□

Dire

ctly

Obs

erve

d Tr

eatm

ent

(DO

T)

□ Fo

llow

-up

of c

ontr

ol a

ppoi

ntm

ents

□ O

ther

– P

leas

e sp

ecify

:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts

C

om

mu

nit

y-b

ased

su

rvei

llan

ce

□ C

hole

ra

□

Flu

□

Men

ingi

tis

□ H

emor

rhag

ic f

ever

s, in

clud

ing

Ebo

la V

irus

Dis

ease

□

Mea

sles

□

Pol

io

□ Y

ello

w f

ever

□

Neo

nata

l tet

anus

□

Gui

nea

wor

m

□ Le

pros

y

□

Mat

erna

l dea

ths

□ N

eona

tal d

eath

s

□ C

lust

ered

dea

ths

□ A

ny s

uspi

ciou

s ca

se, u

nusu

al e

vent

or

rum

or

circ

ulat

ing

in t

he c

omm

unity

□ O

ther

– P

leas

e sp

ecify

: P

leas

e br

iefly

des

crib

e th

e al

ert

mec

hani

sms

in p

lace

:

Par

tially

impl

emen

ted

in --

------

---- d

istr

icts

Fu

lly im

plem

ente

d

in --

------

---- d

istr

icts

O

ther

act

ivit

ies

– P

leas

e sp

ecif

y, a

s w

ell a

s th

e g

rou

p(s

) o

f ag

e th

at r

ecei

ve it

:



CO

MM

UN

ITY

EN

GA

GE

ME

NT

15

Com

mun

ity e

ngag

emen

t

31.

Is t

here

a s

trat

egy

for

com

mun

ity

enga

gem

ent?

□ Y

es, i

nclu

ded

in t

he c

omm

unity

hea

lth p

olic

y/st

rate

gy

□

Yes

, inc

lude

d in

the

hea

lth p

olic

y

□ Y

es, i

nclu

ded

in t

he c

omm

unity

-bas

ed in

terv

entio

ns p

olic

y

□

No,

the

re is

no

such

str

ateg

y

□

Oth

er –

Ple

ase

spec

ify :

32

. A

re t

here

ac

coun

tabi

lity

fram

ewor

k an

d st

ruct

ures

at

all

leve

ls?

□ Y

es

□ N

o If

so,

ple

ase

spec

ify:

33.

Is t

here

a p

ossi

bilit

y fo

r co

mm

uniti

es t

o:

□ ta

ke le

ader

ship

in h

ealth

issu

es

□ ge

t in

volv

ed in

inte

rven

tions

pla

nnin

g, m

onito

ring,

and

eva

luat

ion

□

solv

e pr

oble

ms

at lo

cal l

evel

□ m

obili

ze r

esou

rces

□ O

ther

– P

leas

e sp

ecify

:

34.

Ple

ase

stat

e th

e re

latio

n be

twee

n M

inis

try

of H

ealth

and

lo

cal g

over

nanc

e

35.

Do

the

com

mun

ity

heal

th p

olic

y an

d/or

co

mm

unic

atio

n pl

an

men

tion:

a)

Oth

er v

olun

teer

s th

an C

HW

s (e

.g. n

atio

nal R

ed C

ross

vol

unte

ers)

?

□

Yes

□

No

b)

C

omm

unity

hea

lth c

ente

rs o

r co

mm

unity

-bas

ed f

acili

ties

(e.g

. Esc

om, C

ES

CO

M,

Hea

lth C

ente

rs, e

tc.)?

□ Y

es

□ N

o If

so,

ple

ase

spec

ify h

ow s

uch

stru

ctur

es a

re n

amed

in t

he c

ount

ry:

c)

C

ivil

Soc

iety

Org

aniz

atio

ns o

r ne

twor

ks?

□

Yes

□

No



SU

PP

LY M

AN

AG

EM

EN

T

16

Sup

ply

man

agem

ent

36.

Is t

here

a

proc

urem

ent

plan

(in

clud

ing

Sta

ndar

d O

pera

ting

Pro

cedu

res)

:

□ Y

es

□ N

o If

so,

a)

This

pla

n in

clud

es:

□ m

edic

ines

nee

ded

for

com

mun

ity c

ases

man

agem

ent

□ ne

eded

equ

ipm

ent

□ co

mm

unic

atio

n to

ols

b)

Is t

he c

omm

unity

pro

cure

men

t fo

r m

edic

ines

and

equ

ipm

ent

inte

grat

ed in

to t

he

natio

nal s

uppl

y sy

stem

?

□ Y

es

□ N

o

c)

Is t

he s

yste

m in

pla

ce e

ffec

tive?

□

Yes

□

No

d)

Wha

t ar

e th

e ch

alle

nges

for

com

mun

ity p

rocu

rem

ent?

e)

Wha

t so

lutio

ns c

ould

be

prov

ided

?



SE

RV

ICE

DE

LIV

ER

Y A

ND

RE

FER

RA

L

17

Ser

vice

del

iver

y an

d re

ferr

al

37.

Can

CH

Ws

refe

r to

ap

prop

riate

too

ls

(tra

inin

g m

anua

ls, j

ob

aids

, etc

.) fo

r cl

inic

al

asse

ssm

ent,

di

agno

sis,

m

anag

emen

t an

d re

ferr

al?

□ Y

es

□ N

o C

omm

ents

:

38.

Wha

t is

the

ref

erra

l pr

oced

ure

for

com

mun

ity h

ealth

?

Mul

tiple

res

pons

es a

llow

ed

□ V

erba

l

□

Writ

ten

□

Acc

ompa

nyin

g pa

tient

□ O

ther

– P

leas

e sp

ecify

:

39.

Is t

here

a c

ount

er-

refe

rral

mec

hani

sm?

□

Yes

□

No

If s

o, p

leas

e sp

ecify

:

40.

Are

ref

erra

l cas

es

indi

cate

d in

CH

Ws

repo

rts?

□ Y

es

□ N

o



SU

PE

RV

ISIO

N A

ND

PE

RFO

RM

AN

CE

QU

ALI

TY A

SS

UR

AN

CE

18

Sup

ervi

sion

and

per

form

ance

qua

lity

assu

ranc

e

41.

Is t

here

a C

HW

s su

perv

isio

n pl

an?

□

Yes

□

No

42.

Wha

t is

the

su

perv

isee

/sup

ervi

sor

ratio

?

43.

Who

sup

ervi

ses

CH

Ws?

□

Hea

lth f

acili

ty

Ple

ase

spec

ify w

hich

hea

lthca

re p

rofe

ssio

nal i

n th

e fa

cilit

y:

□ H

ealth

com

mitt

ee

□

Com

mun

ity s

uper

viso

r

□ O

ther

– P

leas

e sp

ecify

:

44.

Wha

t is

the

sup

ervi

sors

tr

aini

ng?

Ple

ase

spec

ify t

he d

urat

ion

of t

rain

ing:

□

------

------

-- da

ys

□ ---

------

------

mon

ths

Ple

ase

brie

fly d

escr

ibe

the

cont

ent

of t

rain

ing:

45.

Are

com

mun

ity h

ealth

sp

ecifi

c su

perv

isio

n to

ols

used

?

□ Y

es

□ N

o C

omm

ents

:

46.

Are

res

ourc

es

(veh

icle

s, f

uel,

etc.

) to

appr

opria

tely

con

duct

su

perv

isio

n an

d pr

ovid

e sk

ills

coac

hing

to

CH

Ws

avai

labl

e?

□ Y

es

□ N

o C

omm

ents

:

47.

How

oft

en s

houl

d C

HW

s su

bmit

a re

port

?

□ N

o re

port

req

uire

d

□

Wee

kly

□ M

onth

ly

□ Q

uart

erly

□ O

ther

– P

leas

e sp

ecify

:



MO

NIT

OR

ING

AN

D E

VALU

ATI

ON

, AN

D C

OM

MU

NIT

Y H

EA

LTH

INFO

RM

ATI

ON

SY

STE

MS

19

Mon

itorin

g an

d ev

alua

tion,

and

com

mun

ity h

ealth

info

rmat

ion

syst

ems

48.

Is t

here

a

com

preh

ensi

ve

mon

itorin

g fr

amew

ork

and

syst

em in

clud

ing

all c

omm

unity

hea

lth

com

pone

nts?

□ Y

es

□ N

o If

so,

doe

s th

is s

yste

m in

clud

e:

a)

wel

l-def

ined

indi

cato

rs?

□ Y

es

□ N

o

b)

base

line

indi

cato

rs?

□ Y

es

□ N

o

c)

expe

cted

res

ults

(qua

ntifi

ed t

arge

t, p

reci

se d

eadl

ine)

?

□ Y

es

□ N

o

d)

clea

r an

d de

taile

d m

echa

nism

(too

ls, f

requ

ency

and

leve

l of

data

col

lect

ion)

?

□

Yes

□

No

e)

m

eans

of

usin

g in

form

atio

n?

□ Y

es

□ N

o

49

. A

re c

omm

unity

hea

lth

data

inte

grat

ed w

ithin

th

e na

tiona

l hea

lth

info

rmat

ion

syst

em?

□ Y

es

□ N

o

If s

o, a

re t

he c

omm

unity

hea

lth d

ata

□ di

sagg

rega

ted

to t

he e

nd o

f th

e na

tiona

l hea

lth in

form

atio

n sy

stem

?

□ am

alga

mat

ed w

ith t

he d

ata

of t

he h

ealth

pos

ts/c

ente

rs?

50

. W

ho is

res

pons

ible

fo

r co

mm

unity

hea

lth

data

con

solid

atio

n?

51

. H

ow a

re c

omm

unity

he

alth

dat

a tr

ansm

itted

?

□ vi

a pa

per

tool

s

□

via

digi

tal t

ools

If

dig

ital t

ools

are

use

d, p

leas

e sp

ecify

a)

To

wha

t sc

ale

is t

his

proc

ess

impl

emen

ted?

b)

W

hat

is t

he t

echn

olog

y us

ed?

52.

Is t

here

a p

lan

for

oper

atio

nal r

esea

rch?

□

Yes

□

No

If

so,

ple

ase

spec

ify, i

ndic

atin

g ob

ject

ives

and

inst

itutio

ns in

volv

ed, a

nd in

clud

ing

ongo

ing

rese

arch

:


COMMUNITY HEALTH POLICIES AND PROGRAMMES...6 Community health policies and programmes List of...

Documents

Transcript of COMMUNITY HEALTH POLICIES AND PROGRAMMES...6 Community health policies and programmes List of...