Community System Strengthening (CSS) Evaluation Report



THE GLOBAL FUND to FIGHT AGAINST AIDS, TB AND MALARIA (GFATM)Report onGLOBAL FUND ROUND 8 HSS GRANT COMMUNITY SYSTEMS STRENGTHENING (CSS) EVALUATION August 20127239007134225Table of Contents TOC \o "2-3" \h \z \t "Heading 1,1" ACKNOWLEDGEMENTS PAGEREF _Toc332957514 \h 1ABBREVIATIONS AND ACRONYMS PAGEREF _Toc332957515 \h 2EXECUTIVE SUMMARY PAGEREF _Toc332957516 \h 4CHAPTER 1: INTRODUCTION PAGEREF _Toc332957517 \h 81.1Background PAGEREF _Toc332957518 \h 81.2CSS programme context PAGEREF _Toc332957519 \h 81.3Objectives of the evaluation study PAGEREF _Toc332957520 \h 9CHAPTER 2: METHODOLOGY PAGEREF _Toc332957521 \h 112.1.Evaluation design PAGEREF _Toc332957522 \h 112.2.2Primary data collection PAGEREF _Toc332957523 \h 112.2.3Data analysis PAGEREF _Toc332957524 \h 122.2.4Limitations of the study PAGEREF _Toc332957525 \h 13CHAPTER 3: FINDINGS- PROGRAM DESIGN PAGEREF _Toc332957526 \h 143.1Programme relevance and quality of design PAGEREF _Toc332957527 \h 143.2Evidence of incorporation of community-based approaches into program strategies PAGEREF _Toc332957528 \h 143.2.1The national health strategy PAGEREF _Toc332957529 \h 143.2.2Program strategies PAGEREF _Toc332957530 \h 153.3CHWs participation and contribution to HIV, TB, malaria and MNCH programs PAGEREF _Toc332957531 \h 163.3.1CHWs participation in the programs PAGEREF _Toc332957532 \h 163.3.2Contribution of CHWs in disease programs PAGEREF _Toc332957533 \h 173.4Sustainability of CHW component beyond GF support PAGEREF _Toc332957534 \h 183.4.1Ownership and recognition of CHWs by the community PAGEREF _Toc332957535 \h 183.4.2Funding of CHW program PAGEREF _Toc332957536 \h 18CHAPTER 4: FINDINGS - PROGRAM IMPLEMENTATION PAGEREF _Toc332957537 \h 214.1Adherence to work plan PAGEREF _Toc332957538 \h 214.1.1Timeliness of implementation PAGEREF _Toc332957539 \h 214.1.2Completeness of implementation PAGEREF _Toc332957540 \h 214.1.3Delivery approaches PAGEREF _Toc332957541 \h 214.1.4Adherence to national guidelines and targets PAGEREF _Toc332957542 \h 224.2Capacity of CHWs to implement planned interventions PAGEREF _Toc332957543 \h 224.2.1Training requirements PAGEREF _Toc332957544 \h 224.2.2Appropriate skills-mix PAGEREF _Toc332957545 \h 234.2.3Adequacy of supervision of CHWs PAGEREF _Toc332957546 \h 234.2.4Adequacy of logistical support PAGEREF _Toc332957547 \h 244.3Coordination and communication between organizations PAGEREF _Toc332957548 \h 244.4Facilitating and inhibiting factors in implementation of CHW programme PAGEREF _Toc332957549 \h 254.4.1Facilitating factors PAGEREF _Toc332957550 \h 254.4.2Inhibiting factors PAGEREF _Toc332957551 \h 29CHAPTER 5: FINDINGS - PROGRAM RESULTS PAGEREF _Toc332957552 \h 305.1Perception of community members and leaders on CHW programme PAGEREF _Toc332957553 \h 305.1.1Strengths and weaknesses PAGEREF _Toc332957554 \h 305.1.2Perceptions PAGEREF _Toc332957555 \h 305.2Results of community interventions PAGEREF _Toc332957556 \h 305.2.1Malaria PAGEREF _Toc332957557 \h 305.2.2HIV/AIDS PAGEREF _Toc332957558 \h 315.2.3TB PAGEREF _Toc332957559 \h 335.3Cost effectiveness of Global Fund support PAGEREF _Toc332957560 \h 33CHAPTER 6: SUMMARY FINDINGS PAGEREF _Toc332957561 \h 35CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS PAGEREF _Toc332957562 \h 367.1Conclusions PAGEREF _Toc332957563 \h 367.1.1Programme design PAGEREF _Toc332957564 \h 367.1.2Programme implementation PAGEREF _Toc332957565 \h 367.1.3Programme results PAGEREF _Toc332957566 \h 367.1.4Potential impact PAGEREF _Toc332957567 \h 367.1.5Sustainability PAGEREF _Toc332957568 \h 367.2Recommendations PAGEREF _Toc332957569 \h 36ANNEXES PAGEREF _Toc332957570 \h 39Annex 1: Terms of Reference for the Zimbabwe CSS Evaluation PAGEREF _Toc332957571 \h 39Annex 2: References PAGEREF _Toc332957572 \h 42Annex 3: Criteria for selection of VHWs PAGEREF _Toc332957573 \h 43Annex 4: Training curriculum for VHWs PAGEREF _Toc332957574 \h 44Annex 5: Training curriculum for CBHWs PAGEREF _Toc332957575 \h 46Annex 6: A Story of Change by the Dumbamwe Clinic CBHC Team PAGEREF _Toc332957576 \h 48Annex 7: Facility Based Examples of Battery Scores Before and After the Training (CHWs) PAGEREF _Toc332957577 \h 50Annex 8: Evaluation Framework PAGEREF _Toc332957578 \h 51Annex 9: List of people met and summaries of CHWs met in FGDs PAGEREF _Toc332957579 \h 56ACKNOWLEDGEMENTSWe would like to thank all the officials of the Ministry of Health and Child Welfare (MoHCW) who participated in this evaluation at national, provincial, district and community levels. To the members of the Country Coordinating Mechanism (CCM) Secretariat and the CCM Health Systems Strengthening (HSS) sub-committee who participated in the feedback consultative meeting we are indebted for their contribution in developing the recommendations of this study. We would also like to appreciate the role played by the provincial and district health leadership team and the many health workers we met including the Mashonaland West Provincial Health Executive (PHE), the Chegutu and Makoni District Health Executives (DHE), Manicaland Provincial Nursing Officer (PNO), the local leadership, the Village Health Workers (VHW) and Community Home Based Caregivers (CHBC). We are also very grateful for the insights that we gathered from the discussions we had with members of the World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) teams particularly the stories shared on the experience gained during the resuscitation of the VHW programme. The revamped VHW programme coincided with the cholera outbreak of 2008-09, a precursor to the decision to allocate further funding from Global Fund and the proposed UNICEF managed Health Transition Fund. Additional inputs were also received from representatives of the Principal Recipient, United Nations Development Programme (UNDP).Notwithstanding all the assistance received and the opinions expressed by those mentioned above and others too many to enumerate, the consulting team takes full responsibility for any errors of commission and omission contained in his report. ABBREVIATIONS AND ACRONYMSAIDSAcquired Immune Deficiency SyndromeANCAntenatal CareARTAnti-Retroviral TherapyARVsAnti-Retroviral (drugs)ASRHAdolescent Sexual and Reproductive HealthCBOCommunity Based OrganisationCCMCountry Coordinating MechanismCHBCCommunity and Home Based Care-giver (C&HBC)CHWCommunity Health WorkerCMAMCommunity Management of Acute MalnutritionCSSCommunity Systems StrengtheningDACDevelopment Assistance CommitteeDBSDry Blood SpotDHEDistrict Health ExecutiveDHISDistrict Health Information SystemDNODistrict Nursing OfficerDOTDirectly Observed TherapyEHTEnvironmental Health TechniciansEIDEarly Infant DiagnosisFGDFocus Group DiscussionFHWFarm Health WorkerGF/GFATMThe Global Fund to fight AIDs, Tuberculosis and MalariaGoZGovernment of ZimbabweHBCHome Based CareHIVHuman Immunodeficiency VirusHMISHealth Management Information SystemHOSPAZHospice Association of ZimbabweHSSHealth Systems StrengtheningHTCHIV Testing and CounsellingHTFHealth Transition FundIECInformation Education and CommunicationIMNCIIntegrated Management of Neonatal and Childhood IllnessesIPImplementing PartnerIPTIntermittent Presumptive TherapyITNInsecticide Treated NetsKIIKey Informant InterviewLLINLong Lasting Insecticidal NetM&EMonitoring and EvaluationMCHMaternal and Child HealthMDGMillennium Development GoalsMDRMulti Drug Resistant (TB)MERMore Efficacious RegimenMNCHMaternal Neonatal and Child HealthMoHCWMinistry of Health and Child WelfareMSCMost Significant ChangeNARFNational AIDs Reporting FormsNGONon Governmental OrganisationOIOpportunistic InfectionsPHCPrimary Health CarePHEProvincial Health ExecutivePLAParticipatory Learning and ActionPLWHAPeople Living With HIV and AIDSPMTCTPrevention of Mother to Child Transmission of HIVPNCPost Natal CarePNOProvincial Nursing OfficerPRPrincipal RecipientPRAParticipatory Reflective and Appraisal techniquesRDCRural District CouncilRHCRural Health CentreRTDRapid Diagnostic Test (Malaria)SRSSimple Random SamplingSTISexually Transmitted InfectionT&CTesting and CounsellingTBTuberculosisUINUnique Identifier NumberUNDPUnited Nations Development ProgrammeUNICEFUnited Nations Children’s FundVCTVoluntary Counselling and TestingVHTVillage Health TeamVHWVillage Health WorkerWASHWater and Sanitation HygieneWHOWorld Health OrganizationZANZimbabwe Aids NetworkZNASPZimbabwe National AIDS Strategic PlanEXECUTIVE SUMMARY0.1BackgroundIn 2009 the Government of Zimbabwe applied for funding assistance from the Global Fund Health Systems Strengthening grant. The goal was to achieve a more effective health delivery system by strengthening the community health systems to ensure that there were trained personnel at community level to provide health services. In April 2012, the Global Fund contracted PricewaterhouseCoopers, the Local Fund Agent to carry out an evaluation study of the Community Health Worker program.The objectives of the evaluation are, to:assess if investments in CHW programs has improved the effectiveness, efficiency and results of the HIV/AIDS, TB and malaria programs in Zimbabwe; and, provide a comprehensive analysis of potential options for improving efficiency and effectiveness of CHW programs, with clear recommendations for preferred options for continued funding. A cross-sectional study that used the mixed method approaches was used to draw primary data from the CHWs, the beneficiary communities and their leaders, other health workers and implementing partners at all levels. Secondary data from disease specific databases was also obtained to identify the impact of the work of CHWs on the GF target disease trends. The main issues investigated were the effects of the GF investments in the CHW program on the HIV/AIDS, TB and malaria programs. An analysis of potential options for improving the CHW programme was also done.0.2Relevance and quality of designThe CHW is in-line with the strategic focus at both the national level and for the individual disease components. For example, the community-based approach is one of the five pillars of the National Health Strategic Plan (2011-2015) which is dedicated to community participation. Seven (22%) of the 32 goals, and 58 (42%) of 138 objectives contained in the strategic plan cannot be implemented effectively and adequately without the involvement of CHWs whose role is critical in implementing the preferred community based approach.There was strong evidence that the CHW program was relevant and appropriate in supporting the primary health care approach anchored on community involvement and participation in improving awareness, access and utilization of health services. At all levels of the health care system, there is an appreciation of the importance and necessity of the contribution of CHWs in supporting the health care system. 0.3Program implementation0.3.1EfficiencyA total of 11,514 CHWs were trained compared to the target of 11,160. This was achieved at an average cost of $8 per person per day over the three weeks compared to the planned cost of $23 per person per day. The program demonstrated efficiency in as far as more CHWs were trained than planned. However, the program was not efficient in the distribution of incentives as fewer CHWs received their allowances from the sixth quarter. 0.3.2EffectivenessThe program was effective in ensuring that there was a trained community cadre who provided both preventive and curative health services. This reduced the distance travelled as well as the cost of transport incurred by members of the community in seeking health services. The program managed to enhance the knowledge and skills of the trained CHWs. The CHBCs were reported to be better positioned to provide quality care to PLWHAs and their families addressing physical, emotional, spiritual and social needs. Similarly, the capacity of the VHWs to provide health education as well as to identify, manage and refer cases was noted to be significant. However the effectiveness of the CHWs was affected by their numerical inadequacy, and inadequate support in terms of supplies, incentives, supportive supervision and mentoring. There is also lack of integration of the VHW reporting system into the Health Information Systems (HIS) resulting in non-transmission and unavailability of VHW performance data at all levels.0.3.3ImpactIn the short time the program has been implemented its impact on the HIV, TB and malaria programs is difficult to discern partly due to the absence of comprehensive performance measurement data. Nonetheless, the impact prospects in the long term are perceived to be good by most of the informants encountered during the study. Already, the training given to the CHWs is reported to have contributed towards improved detection of malaria cases as well as increased participation by members of beneficiary communities during awareness campaigns.0.3.4CoordinationThis VHW program was observed to be operating within established coordination structures of the MoHCW. The VHW component was supervised under the Directorate of Nursing and was recognised at the various supervisory structures (provincial and district levels) of the MoHCW. The coordination of the CHBCs was led by ZAN, HOSPAZ and implementing partners. Broadly, the coordination for both VHWs and CHBCs contributed to the successful implementation of the planned activities.Some gaps were however noted in the coordination of the VHWs. Coordination should recognise the complementary role of all stakeholders in achieving planned goals through regular sharing of results and maintaining proper flow of information. Some key stakeholders were left out of the vital processes such as planning, development of VHW training curricular, training of VHWs, supervision and management meetings.The most essential ingredients of system-strengthening approaches such as strategic leadership, and efforts towards strengthening linkages between the vital parts/levels of the system were suboptimal. This limits the ability of the CSS grant to materially affect the build-up of results towards achievement of the goals of the National Health Strategic Plan. 0.4Sustainability of resultsAlthough currently the Government of Zimbabwe is still facing liquidity challenges as the economy undergoes the recovery process, there are indications that the CHW programme will remain a critical component of the National Health Strategy. Therefore, in the short and medium term, donor funding will be crucial in sustaining current efforts in supporting the Health System in general including the CSS program. In addition, it was noted that the Global Fund is supporting the CSS program through the HSS grant as well as through the other three disease specific grants under Round 8 Phase 1 and Phase 2. The desired position is for the GoZ to progressively increase funding for CHWs program in the long term.0.5RecommendationsBased on these findings, the following recommendations are hereby proffered to GFATM and stakeholders in the CSS Program: Harmonization and standardization of trainingThere is need to have one standardised training manual for the different groups of CHWs and this should be based on the harmonization of the integrated VHW and CBHC training modules. There should be a minimum training package for all community health workers, which should be developed in consultation and active involvement of all the relevant departments like Environmental Health, Nursing, Health Promotion, MCH, HMIS to name but a few. An annual mapping exercise should be conducted that provides for the identification of CHWs by District, contact Health facility, level of training, community of responsibility, and schedule of incentives to be received and/or received to date. It is envisaged that harmonization and standardization of the training of the VHW and CBHC training packages would contribute to improvements in numerical adequacy of the CHWs. The mapping exercise would also identify who is doing what, where in terms of partner support for CSS so that further efforts can be directed to ensure equity. Incentive packageThere is need for a standardised incentive package across the CHWs, and improve transparency and communication around the incentives vis-à-vis commensurate facilitation for CHW workload.Procurement and supply management of pharmaceutical and medical productsThere is need to strengthen the overall supply chain systems to ensure reliable and adequate pharmaceuticals and supplies for health facilities that take into account the needs of the CHWs. Supervision, support and mentorshipThe current support and supervision should first and foremost emphasise frequency of support visits from the focal health facility to the CHWs in their workplaces. Deliberate efforts toward balancing the interactions of both the nurse and the EHT in supervising the CHWs will go a long way in improving the technical capacity, scope of both preventive and curative interventions as well as and quality of services provided by the CHW. Monitoring and evaluationThe CHWs should be regularly and more reliably provided with registers and simplified summary reporting forms. The HMIS and DHIS should be revised to provide sections for CHW reporting. A comprehensive M&E framework and system that includes a set of indicators on provision of necessary inputs, CHW service coverage, and means of measuring performance of the CSS programme should also be developed.CoordinationThere is need for a shared understanding of the results the CSS programme seeks to achieve in order to improve health service delivery in the country (strategies, goals and objectives), as well as promote clarity and commonality of purpose among key CHW user departments. Given the cross-departmental and integrated management nature of the CSS grant, there is need to separate the strategic and operational functions of the CSS program management through establishment of a ‘home’ to coordinate the routine operational and administrative affairs of the CSS program. Sustainability and options for continued fundingThe Government is encouraged to continue increasing their allocation and disbursements to the programme from the current 6.7 % towards 100% of total need in the long term. We further recommend that incentives such as allowances, uniforms and bicycles be considered a necessary component of the CSS programs at all times. The Global Fund should provide funding for the component through one grant, the HSS grant to enable a more centralised coordination of the trainings of the CHWs. At the moment funding for the component is provided through all the four grants. CHAPTER 1: INTRODUCTION BackgroundIn 2009, the Government of Zimbabwe (GoZ) successfully applied for grant funding under the Round 8 of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), Health Systems Strengthening (HSS) program. The program was established as a crosscutting grant whose goal was to achieve a strengthened and more effective health delivery system through: retention of the health sector workforce; strengthening community health systems; and, raising the scale of operation of community programs focusing on HIV/AIDS, TB and malaria. The component focusing on strengthening Community Health Systems was aimed at ensuring that there were sufficient numbers of trained staff at community level to provide health services. In line with the GFTAM funding mechanisms, UNDP, the Principal Recipient for the GF has since 2010 (when the GF Round 8 grants were first implemented) been overseeing the implementation of the grant aimed at providing support to the Community Health Workers (CHW) under the management of the Ministry of Health and Child Welfare (MoHCW) and Zimbabwe AIDS Network (ZAN). The MoHCW is responsible for managing the Village Health Worker (VHW) sub-component while ZAN is responsible for the Community Home Based Care Givers (CHBC) sub-component. The funding for the whole component was targeted at supporting the training of CHW and the provision of allowances and uniforms to complement other Government efforts. In April 2012 the Global Fund engaged PricewaterhouseCoopers (PwC), the Local Fund Agent, to carry out an evaluation of the Community Systems Strengthening component in partial fulfillment of the conditions for signing of the HSS Phase 2 Grant. 1.2CSS programme contextService delivery in the health sector is predicated on a two pronged approach. On one hand is the primary health care approach (PHC) which emphasizes the prevention of diseases and the promotion of health in the family and the community as a whole. On the other hand, the medical care approach focuses on helping individuals after they have fallen ill. It is important that these two approaches complement each other to ensure effective delivery of health care services. Several attempts have been made to achieve this objective resulting in the CHW programme being placed under different government bodies to play different roles within the community, at different times since its inception. For example, during the 1990s the programme was under the oversight of both the Nursing and Environmental Health departments, when it was realised that both departments needed to collaborate closely in order to achieve a more holistic and better capacitated community cadre. CSS programme managementThe provision of training, supplies and the implementation of community work by the CHWs complemented by incentives and on-going supervision by health workers define the key processes of the model used for the CSS programme. These processes require essential inputs which include: health professionals; national strategic documents to provide guidance; strong Monitoring and Evaluation Systems; a good coordination mechanism; committed members of the community who meet the criteria and are willing to do the work; funds for transportation; venues and other workshop expenses; training modules; supplies for use in the field; as well as incentives for the CHWs. It is therefore clear that the coordination mechanism for the CSS needs to involve the nursing as well as the environmental health and health promotion departments/sections of the MoHCW, and the relevant development and implementation partners. In order to monitor the activities of the CHWs, follow disease trends, plan supplies and logistics and support supervision, such coordination mechanisms also needs to be replicated all the relevant levels (provincial, district and health facilities).Expected results of CSS The work of the trained CHWs is mainly to provide preventive and promotional health services but with occasional treatment of minor ailments in the communities. Health education and promotion, case identification and referral as well as community mobilisation are therefore significant activities undertaken by the CHWs particularly the VHW. These activities should contribute to the realisation of health related results in the short, medium and long term. The programme is expected to position a trained and committed cadre facilitating prevention through awareness and education, early identification of cases and referrals as well as generally responding to the health needs of the community. These activities are also expected to improve awareness of available health services and participation by the community. The existence of numerically adequate and capacitated CHWs in terms of knowledge, skills and resources is envisaged to result in improved access to health services and positive change in the communities’ health seeking behaviour. The latter is largely characterized by enhanced utilization of the available health services. In the medium term, improvements are expected in the uptake of antenatal care, post natal care, immunization, family planning and voluntary counselling and testing. These results collectively contribute to the reduction in morbidity and mortality within the communities and the attainment of the Millennium Development Goals (MDGs) at the broader level. Figure 1 illustrates the CSS programme theory of change.1.3Objectives of the evaluation studyThe key objectives of the evaluation are, to: assess if investments in CHW programs, has improved the effectiveness, efficiency and results of the HIV/AIDS, TB and malaria programs in Zimbabwe; and, provide a comprehensive analysis of potential options for improving efficiency and effectiveness of CHW programs, with clear recommendations for preferred options for continued funding. The intervention logic of the CSS programme was an essential entry point for this evaluation. Consultations with key stakeholder representatives and a review of the National Strategic Plans and HSS/CSS proposal were useful in defining the programme’s intended results. A review of documents and consultations with key stakeholder representatives clarified the mechanism established to manage the CHW programme at strategic, operational and tactical levels17526036830INPUTSHealth professional (Trainers, supervisors)Vehicles, fuel, training venues, stationeryStrategic plans and guidelinesStandard training modulesSimple treatment kits/suppliesCHW KitsTools and Incentives (Allowances, bicycles, uniforms, stationery)Community members meeting CHW criteriaPROCESSES- Health ProfessionalTrainingSupport & supervisionSupply ReplenishmentProvision of allowances Provision of uniforms, bicycles, tool kits, torchesRecording/Report writingThe “Three Ones”PROCESSES- CHWHealth educationHealth promotionTreatment of minor illnessesCase identification and referralCommunity mobilisationRecording/Report writingOUTPUTSTrained CHWsCommunity coverage of health informationCommunity awareness of available health servicesCases identified and managed or referredImproved participation in community healthOUTCOMESImproved awareness and use of preventive methods incl. hygiene and nutrition practicesEquitable access to available health servicesImproved health seeking behaviour: Uptake of ANC, PNC, EPI, FP and VCTImproved reception of referred casesImproved detection of outbreaksIMPACTReduction in morbidity and mortality/Attainment of the MDGs/Eradicate disease00INPUTSHealth professional (Trainers, supervisors)Vehicles, fuel, training venues, stationeryStrategic plans and guidelinesStandard training modulesSimple treatment kits/suppliesCHW KitsTools and Incentives (Allowances, bicycles, uniforms, stationery)Community members meeting CHW criteriaPROCESSES- Health ProfessionalTrainingSupport & supervisionSupply ReplenishmentProvision of allowances Provision of uniforms, bicycles, tool kits, torchesRecording/Report writingThe “Three Ones”PROCESSES- CHWHealth educationHealth promotionTreatment of minor illnessesCase identification and referralCommunity mobilisationRecording/Report writingOUTPUTSTrained CHWsCommunity coverage of health informationCommunity awareness of available health servicesCases identified and managed or referredImproved participation in community healthOUTCOMESImproved awareness and use of preventive methods incl. hygiene and nutrition practicesEquitable access to available health servicesImproved health seeking behaviour: Uptake of ANC, PNC, EPI, FP and VCTImproved reception of referred casesImproved detection of outbreaksIMPACTReduction in morbidity and mortality/Attainment of the MDGs/Eradicate diseaseFigure1: CSS Project Theory of Change.CHAPTER 2: METHODOLOGY2.1.Evaluation design The Development Assistance Committee (DAC) of Organisation of Economic Cooperation and Development (OECD) has developed comprehensive criteria for carrying out evaluation studies. The guidelines developed focus on assessing the following attributes: relevance and quality of design, efficiency, effectiveness, impact and sustainability of program initiatives. The consulting team adapted the DAC criteria to match the requirements of the terms of reference as given in Annex 1. The research questions formed the basis of the Evaluation Framework that specifically outlined the approaches to inquiry and analysis in answering the questions. The evaluation used a Cross-sectional Study Design that employed a Mixed Method Approach, which relied on the use of both quantitative and qualitative methods (though largely skewed towards the latter) in drawing data from programme beneficiaries, programme implementers and other stakeholders at district and national level. The district level stakeholder representatives included community members and their leaders as well as local health professionals whilst consultation at the national level included MoHCW officials, ZAN, HOSPAZ, UNICEF, WHO and CCM representatives. The data obtained through the various data collection methods collectively contributed to providing the comprehensive picture relating to the performance of CHWs, the program and its contribution to desired health outcomes. The analysis of qualitative data (from primary and secondary sources) was largely based on content analysis and use of the grounded theory for the analysis and interpretation of qualitative data. Similar issues emerging from the different sources of information were grouped together by thematic area and analyzed to establish key conclusions of the analysis. 2.2Data collection2.2.1Secondary data reviewThe primary data collected was preceded by a review of the GF target disease program’s secondary data in order to assess effect and change over time. Secondary data reviewed included programme and national data as well as reports drawn from the National Health Management Information System (HMIS), specific department databases (Malaria Control Programme, AIDS and TB Unit), and the CHBC Programme database for the period under review. Analysis of secondary data generally focused on programme data on reach, access, utilisation and finance.2.2.2Primary data collection Sampling methodologyTwo districts, Makoni and Chegutu were randomly selected for field visits aimed at obtaining district level data primarily from the community members, the CHWs and health professionals. It is important to note that due to low coverage in the primary data, the findings based on the CHW interviews and FGDs are largely indicative and not necessarily representative of all CHWs. However, due to the inclusion of secondary data including key informants at national, provincial and district level, the findings of the evaluation are inferable to the whole Global Fund supported CSS programme in Zimbabwe. Fieldwork The fieldwork was guided by a detailed protocol and was characterised by field planning and scheduling, community and stakeholder involvement in the data collection, a focus on quality assurance and observance of ethics in research.The evaluation team managed to conduct 12 Focus Group Discussions (FGD) in all, 7 in Chegutu District and 5 in Makoni District. While most of the discussions held in both districts involved mostly the VHWs and CBHCs, at Makoni Rural Hospital the participants comprised mainly community leaders due to the logistical problems encountered in reaching the VHWs and the CBHCs (see Annex 9 for details of the people met). In all the discussions and interviews conducted the consulting team endeavoured to ensure that all the participants were exposed to all the evaluation questions. Primary data was collected by way of FGDs with CHWs and community members; as well as Key Informant Interviews (KIIs) with stakeholder representatives using guides and data collection instruments specifically designed for the purpose. The FGDs and other processes were augmented by the use of Participatory Reflective and Appraisal (PRA) Techniques including the Most Significant Change approach in documenting change. Data extraction was employed to draw relevant secondary data for analysis from the various data sources.Key informant interviewsWith the aid of a KII Guide developed for the purpose, the evaluation obtained information from the key informants selected at the various levels. The guide comprised a list of questions and prompts compiled under specific thematic areas of inquiry that were structured to guide the interviewer in facilitating a discussion with the informant. The primary purpose of the KIIs was gather evidence on the informants’ perceptions and opinions on the specific issues discussed as well as to triangulate the information obtained from other sources. Focus group discussionsDiscussions were held with representatives of beneficiary communities, CHWs and community leaders in order to establish their perceptions, opinions and attitudes on the effectiveness of the programme, strengths and weaknesses as well as the change brought about by the programme to date. FGD Guides were used to facilitate the discussions and these comprised a list of open-ended questions for discussions combined with Participatory Learning and Action (PLA) exercises to facilitate respondents’ participation in-line with the focus areas. The PLA exercises included:the Battery Technique;the Proportional Piling Technique; anda strength-weaknesses-opportunities-threats (SWOT) analysis.The FGDs were complemented by observation of the work that the CHWs have been conducting. This served to triangulate the information drawn from other approaches. 2.2.3Data analysisTrends for routine HMIS and program data were plotted and comparisons made over time. Output level data such as the number of trained, active and supported CHWs, caseload and coverage and contacts over specified periods as well as change in knowledge and skills levels was obtained to ascertain the effectiveness of the program. The financial analysis included a review of the Budget versus Work plan, and Expenditure versus Set targets. 2.2.4Limitations of the studyIn reading the findings of this study it is important to take note of the limitations that were encountered by the consulting team, namely: study coverage and sample size; non-existence of control sites; and, the non-availability of data on CHWs in the official health sector management information system.Study coverage and sample size The number of provinces, districts and sites covered in the primary data collection for CHW data is not adequate to provide inference at the national level. However, this data was very useful in shaping the consultations with national level stakeholders and in guiding the secondary data extraction and analysis. The primary data provided a good indication of what is actually happening on the ground regarding the CHW activities, performance and challenges.Non-existence of control sites The evaluation design was initially intended to carry out a comparative analysis of performance and health outcomes at GF funded sites and non-GF funded sites. This design was based on the understanding that within the districts there could be wards and facilities that have not received support for VHWs and CHBCs. The reality however is that the resources and support for CHWs (particularly the VHWs) was spread across the districts such that all facilities would have at least one VHW trained and supported with an incentive package. This therefore implied that the comparison as initially intended by the consulting team was not possible due to contamination.Non-availability of CHW data in the official health sector management information system Data relating to the work and performance of CHWs has not been captured in the HMIS. An assessment of performance, analysis to establish attribution and the extent of significance of the CHW contribution to health outcomes could therefore not be conducted in the absence of such data. The data on CHBC based on the CHBC Program database was useful in providing a picture of the work done by CHBCs but could not be directly linked with data in the HMIS or OI/ART databases. In the absence of adequate CHBC data, the disease specific service provision and utilization data was used as a proxy for gauging the influence of the work of CHWs on the utilization of services. Community perceptions of change and the accompanying factors were also sought to understand the national trends derived from secondary data analysis. CHAPTER 3: FINDINGS- PROGRAM DESIGN3.1Programme relevance and quality of designThe CSS program is a relevant and appropriate intervention. There is consensus amongst stakeholder representatives that the CHWs serve to bridge the gap between the communities and the formal health care system. The GoZ acknowledges the important role played by communities in improving access to health care services in the country. Since 1980 it was realised that the ability and capacity of communities to participate in health development activities depends on the decision making space they enjoy and the degree to which they control the resources available to them to carry through those decisions. It is in view of this fact that the health services sector has placed the active participation of communities in facilitating service delivery on the health development agenda. Since 2000 Zimbabwe has experienced a decade of economic and social decline resulting in the exodus of skilled personnel and the deterioration of infrastructure which have compromised efforts by the government and its development partners in providing universal access to basic health services and the combat of HIV/AIDS, TB and malaria. The CHW programme was revitalised to reverse the adverse impact of a weak health delivery system and to improve access to health services at the primary level. The CHW cadre was not new to the communities and the CSS program was a revitalisation of the Village Community Worker introduced in the early 1980’s. The program as a whole is in-line with the provisions of the national health strategy as well as the strategies of the individual disease components supported under the GF grant, namely HIV/AIDS, TB and malaria. 3.2Evidence of incorporation of community-based approaches into program strategies3.2.1The national health strategyThe National Health Strategic Plan for Zimbabwe 2009 to 2013 recognises that good health and quality of life do not derive only from the health sector, but are influenced by a myriad of other factors which are outside its direct influence. It focuses on three key result areas namely: improving the health status of the population; improving the quality of care; and strengthening health systems. The mission statement is anchored on, among others, the Primary Health Care (PHC) approach as a leading strategy for health development, developing innovative and new approaches in management and delivery of services in ways that enhance access, community satisfaction and local accountability, widening participation and the awareness of social determinants of health. The plan aims to keep as many people as possible in good health in the community through health protection, health promotion and disease prevention strategies before providing quality care at various levels of specialization. The new strategic focus hinges heavily on community participation as one out of the five pillars of the strategic plan. The strategic plan has 32 goals depending on 138 objectives for their achievement. However, 7 of the goals, and altogether 58 (42%) of these objectives cannot be adequately and effectively implemented without involvement of the CHW through community approaches. The strategic plan also provides for the cross cutting health systems strengthening areas that include service delivery, health information, financing, medical commodities supplies and logistics, as well as leadership and governance as critical success factors. This is done in the overriding spirit of the three ones (i.e. one strategic plan, one M&E framework and one coordinating mechanism), whose execution and strategies to achieve long term health impact are well documented in the different sections of the strategic plans. This further reinforces the relevance and appropriateness of the CSS, a timely and supportive intervention for the other disease components. 3.2.2Program strategiesThe Zimbabwe National HIV and AIDS strategyThe national thrust to strengthen community participation and involvement in the provision of health care services has been taken up at disease component level. One of the key principles of the ZNASP is the need to strengthen a multi-sectorial approach in the fight against HIV/AIDS. The CHBC component has been identified as key in the ZNASP. The national AIDS policy recognises CHBC services as an extension of the health care delivery system that has to be fully developed and supported as an essential component of the continuum of care for PLWHA.The national plan for the provision of ART (2008-2012) recognises the role played by communities in ART follow-up. The plan also recognises the need to harmonise CHW training materials into a national standard CHW training program. It is acknowledged that individuals, families and communities play an essential role in providing care to clients and thus their involvement is considered very important in the fight against HIV/AIDS. The National Tuberculosis strategyThe national TB strategy (2010-2014) recognises the complementary role played by communities, CBOs and NGOs in providing TB services. The range of services provided by these partners include patient support, including direct observation of treatment (DOT), patient, family and community TB related education, supporting case finding activities and lobbying for greater government support for TB control. The strategy while acknowledging the weak implementation of community TB care recognises the existence of the CHBC program for HIV/AIDS as an opportunity for enhancing the community TB care service offering. The strategy recognises that community participation in health care delivery is a key component of the PHC system. The involvement of the community should enhance case finding and case holding thereby contributing to improved program outcomes. The NTP will promote and strengthen community DOTS in all districts of the country through: development of policy, guidelines and training materials on community DOTS, including the TB patient charter; training of stakeholder representatives on community DOTS;introduction of phased implementation of community DOTS; and,provision of supportive supervision and monitoring of community DOTS. The National Malaria Control strategyThe National Malaria Control Program also recognises the value and importance of the communities in program implementation. The NMCP coordinates program implementation through the Provincial Medical Directors (PMD), who in-turn are supported by the Provincial Health Executive (PHE). At the district level (the implementation level), the District Medical Officer (DMO) is responsible for malaria activities and coordinates with the Rural Health Council (RHC) staff, Ward Health Teams (WHTs) and CHWs. There are clear communication and reporting lines through the administrative levels in the health system.In-line with the universal access to the malaria interventions, the strategy seeks to ensure that the new treatment policy is cascaded down to the community based health workers after training on use of ACTs and RDTs. The NMCP endeavours to take all the necessary steps to ensure that the new anti-malarial drug, coartemether, which is registered as a prescription drug is delisted to enable its dispensing at community level. Other issues relating to the use of RDTs and the handling of blood samples by the community-based health workers will also be addressed during the period covered by the strategic plan.3.3CHWs participation and contribution to HIV, TB, malaria and MNCH programs3.3.1CHWs participation in the programsThere are two main categories of health workers found in the communities, namely: the VHWs and the CHBCs. The VHWs are managed by MoHCW whereas the CHBCs are managed by NGOs and CBOs. The CSS Program provided support to both sets of CHWs and therefore their impact on the specific program components is worth evaluating. In addition, there are some community volunteers who are engaged by the individual program components for specific time-bound health related activities. These volunteers include: those involved in distributing condoms; the behaviour change facilitators; those involved in distributing treated nets; and, DOTs observers. Due to the ad hoc nature of their involvement, the volunteers were not involved in the evaluation study. The Village Health WorkerThe VHWs are ordinary members of the community who volunteer to render community health services, serving as the link between the clinic and the community. VHWs work as part-time volunteers carrying out health related activities such as educating and motivating the communities in the prevention of both communicable and non-communicable diseases as well as other health conditions in the community. The criteria used in identifying and appointing VHWs places emphasis on the following attributes:ability to read and write; maturity, stipulating that one must be at least 25 years of age; permanent residence within the community served. Unmarried males and females are excluded from the selection of VHWs since they are perceived to be most susceptible to migration pressures;demonstrated interest in community health work and developmental issues;a respected member of the community;good public relations and an approachable personality; ability to educate and motivate other community members to take up and maintain good health practices. This selection criteria is outlined in the VHW Handbook used by the MoHCW and is therefore available for use by the communities and their leadership in guiding the process identifying suitable candidates. VHWs work between 4 to 7 half-days a week although when there are disease outbreaks or during national immunisation campaigns they work 4 to 5 full days a week as demand for their services tends to increase. The VHW are supervised by the staff from the clinic they are affiliated to. The Community and Home Based CaregiversCommunity and Home Based Caregivers (CHBCs) are members of the beneficiary communities serving as a link between the clinic and the community but primarily focusing on providing care and support services to people living with HIV/AIDS (PLWHA). They work as secondary caregivers to patients afflicted by HIV/AIDS related illnesses usually after they have been discharged from the hospitals. Their work involves maintaining regular contact with the patients and their primary caregivers, undertaking such roles as providing care and support to the client and training family members in how to best provide psychosocial support and palliative care to the patients. They are trained in home based care provided by different NGOs for PLWHA in their communities. They are supervised by the NGOs that train and support them. Most community caregivers volunteered to work, while a few were selected in the same way as VHWs. 3.3.2Contribution of CHWs in disease programsThe responsibilities of VHWs and CHBCs are similar, only differing in that community caregivers’ have generally been confined to providing HBC and support mainly to PLWHA whereas the work done by VHWs is all encompassing going beyond focusing on HIV/AIDS related illnesses. The responsibilities stated provide ample evidence that CHWs participate and contribute to the fight against HIV, TB and malaria (see Table 1). Table 1: Responsibilities of Community Health WorkersThe responsibilities of Village Health Workers (VHWs)To educate the individuals and communities on health related issues, health promotion and disease prevention for both communicable and non-communicable diseases (including hypertension, diabetes, HIV/AIDS related illnesses, stroke) Identifying and referring suspected malaria cases to the health facilities for diagnosis and treatment. To encourage women to breast feed and present their babies for immunisation Conduct follow-up visits and supervision of TB patients on DOTS treatment at community levelProvide information on HIV/AIDS and HBC management and rehabilitation. Support outreach programmes including growth monitoring and providing school health servicesConduct health promotion activities on WASH, ANC, PNC and family planningCollect information, data and maintain a record of members of households receiving and requiring support and use it for planning purposes Collecting data required for reporting and monitoring and evaluation to the RHC. They submit reports every month to the clinic using a standardised form.The responsibilities of Community and Home Based Caregivers (CHBC)Maintaining regular contact with HBC clients and their families providing training to family members in how to best care for their patients. They also provide physical, emotional and spiritual support to both the clients and family membersImpart practical caring skills to primary caregiversIdentifying and referring clients to clinics and other health service providers for VCT, OI and ART services.Providing health education information on specific topics such as ART, the possibility of developing TB and how to recognise it, pain medication, nutrition and hygiene Monitoring use and adherence to medication Promoting uptake, use of condoms as well as distributing these and other IEC materialsCommunity mobilization to discourage the discrimination and stigmatisation of PLWHAProviding supportive counselling to persons requiring such and encouraging them to utilise available HIV and AIDS services 3.4Sustainability of CHW component beyond GF support3.4.1Ownership and recognition of CHWs by the communityThere are strong indications that CHWs are likely to continue providing services in the community beyond the period supported by the Global Fund. It has been observed that CHW programmes are governed and owned by the beneficiary communities. The community plays a significant role in various aspects of the programme including: the selection of CHWs; supporting the cadres; as well as, in providing community level accountability platforms, even though this is not formalised. The community is involved in the selection of the CHWs through a community voting system based on community-defined criteria. In most of the communities served there is a critical mass of committed and literate individuals willing to provide the service. The community also provides a platform (though informal) for accountability as members through the leadership can also influence whether a CHW is retained or dismissed. However, the consulting team also noted that due to high levels of poverty, most members of the communities served do not have the means to contribute towards any significant material incentive packages that could be offered to the CHWs. The CHWs have been noted to be motivated by other intrinsic factors that contribute to their retention. For example, there is a strong sense of ownership and recognition of the cadre by the community. The CHWs appreciate the receptive nature and willingness to adopt recommendations by members of the community. It is however important to note that the virtues and focus of CHWs as well as the extent to which these factors are motivational differs from one individual to another and with the times. Since these factors cannot be quantified they cannot be relied upon as the basis for motivating the CHWs. All groups interviewed pointed to the likelihood of compromised quality of service due to attrition amongst CHWs in the absence of a formal package of incentives including allowances, uniforms and bicycles. The formalisation of the incentive package is therefore deemed a necessary component of the CSS programme particularly after GF support is terminated.Despite some inadequacies in provision of supplies, incentives, supervision and coordination, the CHWs have proved a useful bridge between the communities and the formal health care system. 3.4.2Funding of CHW programGovernment contributionSince the adoption of the PHC strategy in 1980, the government has played a key role in the training, support and supervision of the CHWs. The MoHCW has provided the training venues, tutors and supported the development of the training curriculum for the VHWs. The recruited personnel have also been provided with kits comprising medical supplies used to provide basic health care services to the communities. These supplies include painkillers, anti-malarial medication, bandages, eye and wound ointments. In each province and district there are established CHW trainers and “trainers of trainers” within the ranks of the MoHCW structures. The MoHCW has made it policy that every partner who intends to support the programme should do so through the existing MoHCW structures. To date, most of the support received from partners has been applied towards funding training activities.There has been notable deterioration and in some cases the collapse of basic social services in the country, particularly during the period 2000 to 2008. As a result, the coverage of key health interventions in Zimbabwe decreased significantly. Given that this coincided with a period during which the HIV/AIDS pandemic was at its worst, the country’s performance on key health indicators show a downward trend between 1990 and 2009.Against the background of severe economic circumstances and limited fiscal space, funding the health sector has become a big challenge for the Zimbabwe government. The overall budget allocation to the public health sector has remained low at less than 10 percent of annual budget against the agreed Abuja target of at least 15 per cent. In 2011, the MoHCW was allocated per capita expenditure of $19.7 against a target of $34. The reduction in funding of the health sector from central government over the past decade has led to the reduction of funding allocated for the CHW program. An analysis of expenditure records shows that even when efforts are made to allocate decent amounts to the various budget items the government has struggled raise the allocated amounts leading a situation where actual expenditure is substantially less than the budget amounts. Table 2 shows that the Ministry of Finance only managed to release $420 of the budgeted of $2.3 million in 2009 and $32,912 of the budgeted $1.0 million 2011. In view of the resource constraints faced by central government, much of the funding for the health sector has been provided by development partners mainly from external sources. This trend is likely to continue in the short to medium term and therefore it is unlikely that the projected budget figures shown in Table2 for the 2012 to 2014 period will be realised unless there are significant changes in the political and economic fortunes of the country over the same period. Table 2: Government budgetary allocation to the VHW programme2009 Budget Estimate ($)2009Expenditure ($)2011 Budget Estimate ($)2011 Expenditure ($)2012 Budget Estimate ($)2013 Budget Estimate ($)2014 Budget Estimate ($)2,301,0004201,000,00032,912870,000920,000958,000Source; Ministry of Finance 2010 & 2012 National BudgetContributions received from other development partnersSince the adoption of the primary health care approach by government, various development partners have supported the CHW approach in different ways ranging from funding for training to the provision of incentives. The renewed impetus to strengthen the community health systems in response to the 1998/9 cholera outbreak brought in various other development and technical partners to support the program. After the adoption and adaption of the initiative by the Global Fund, various partners have continued to support the programmes in different districts in different ways. Most support has come in the form of training with some partners also providing bicycles and bags. Some of the partners that have been active in this regard are UNICEF, WHO, Save the Children, World Vision, Zvitambo, Goal, UNDP and Merlin. In 2011, a $70 million multi-donor initiative, the Health Transition Fund (HTF) was created to support the country’s efforts towards realising the MDG 4 and 5 that are meant to address maternal and child health issues. The need to strengthen community health systems is considered a priority area under this initiative. The program has allocated a budget of $4,193,000 towards the review of the VHW training manual taking into account the following issues: current HIV/AIDS information on maternal, new born and child health including PMTCT, IMNCI; reorientation of VHW trainers using the revised VHW training manual; training of 5,000 VHW; procurement of VHW utility kits; payment of allowances for 5,000 VHWs; recruitment of a full time VHW coordinator; and, training of Environmental Health Assistants (EHTs).CSS funding gap analysisTable 3 shows the funding gap up to the end of 2014 taking into account the funding available or committed to the CSS programme by government and other development partners. The total funding requirement is estimated based on the need to support about 17,000 CHWs as indicated in the HTF. The needs include annual training, provision of allowances and the CHW kit. Government contribution to the program is currently estimated at less than 6 per cent of the total requirements at the moment.Table 3: CSS funding gap estimatesFunding sourceYear201220132014GoZ870,000920,000958,000GF HSS grant (Allowances +uniforms for 11260 CHWs)2,124,987.382,182,0942,182,094GF HIV grant (Training of community cadres in linkages between FP and HIV service delivery47,90047,900-GF TB grant (Training of community health workers on community TB care and DOT)68,900GF Malaria grant (Supervision by health care workers of CHWs of ACT and RDT use)90,000120,00090,000GF Malaria grant (Training of community based health workers in malaria prevention and control methods)92,84092,840HTF ( training, allowances and CHW kits for 5000 CHWs)4,193,000No dataNo dataTotal available5,200,9003,431,7343,322,934Total Need12,981,20012,981,20012,981,200Funding Gap7,780,3009,549,4669,658,266Source; 2011 National budget, GF Phase 2 grants and the HTF Year 1 work planIt is clear that GF funding for the programme has been fragmented with allocations meant to support the training of CHWs spread across all the grants. It would be more effective and efficient for the Global Fund to provide funding for the component through a single channel, the HSS grant. The gap analysis in Table 3 clearly shows that the financing requirements for implementation of the identified strategies will be heavily dependent on support from development partners in the short to medium term. It is however encouraging that the prospects for the sustainability of the initiatives are good because of the existence of a conducive institutional framework. The CHW programme has been implemented in-line with the existing MoHCW structures with the active involvement of community structures. While the provision of funding from the central government is currently well below the required levels it is envisaged that this situation will improve as the country’s economic fortunes improve with the stabilisation of the political environment in the medium to long term. In addition, the sustainability of the CHW initiatives is assured given that most of the technology applied is well known and it is envisaged that the approach to implementation will be improved gradually through continuous learning, documentation, dissemination and sharing of best practices. CHAPTER 4: FINDINGS - PROGRAM IMPLEMENTATION 4.1Adherence to work plan4.1.1Timeliness of implementation The training of CHWs was implemented on time where all the initial training was completed in Year 1 of the grant as planned. However, not all incentives and uniforms were provided for during the planned period. Allowances for MoHCW were paid up to quarter 6 (June 2011). No allowances were paid in quarters Q7 and Q8 due to non-disbursement of funds from Global Fund. Payment of allowances was also erratic due to poor timeliness of acquittals from lower levels to national levels. Disbursement decisions by the PR under the grants were based on an 80% acquittal threshold. It was in many cases difficult to reach the threshold since the allowances were not paid monthly but at the end of the quarter. The funds for the allowances were later disbursed in Q9 and Q10. In the workplan, both sets of uniforms were to be provided by Q7. However, the last batch was paid for and delivered in Q10, April 2012 due to delays in disbursement of funds.4.1.2Completeness of implementationThe figures cited under the HTF show that the national target for the CHWs has been estimated at 17,000. Although the CSS program target was set at 11,160 CHWs a total of 11,514 CHWs were trained. However the additional support provided under the programme (uniforms and allowances) was meant to cater for only 180 CHWs in each district. As a result, there are many reported cases of people who benefited from the training who are have not been allocated uniforms and are not receiving the allowances. The ideal training programme for VHWs should cover a period of 20 weeks comprising 8 weeks of classroom training, 8 weeks of field practicals and 4 weeks of additional theoretical training. Due to funding limitations, the GF supported programme provided resources to cover three weeks of training for VHWs, with the entire 8-week curriculum crammed into the shorter period.Lack of provision for translation of the curricula to local languages meant that some of the training materials had to be translated by trainers during training, which may have resulted in limited uptake of the knowledge and misinformation at worst. Modules on the prevention and treatment of TB and Malaria were reportedly understood better as these two diseases have been endemic in the community for a much longer period. Variation in performance amongst the various cadres across the different duration of training exposures was not measured in this evaluation, but there is a high likelihood their performance abilities may differ depending on the nature and duration of training. 4.1.3Delivery approachesTraining was conducted by designated nurses at designated places at local level. Selection of VHW candidates was done at community level. The trainers used the available training curriculum. Coverage of the curriculum was limited to the available 3 week period. For the CHBCs the implementing CBOs in conjunction with the local NAC structures identified volunteer candidates. These candidates were trained for a period of two weeks. This is the designated period for training CHBCs using the existing curriculum.The incentive, $15 per month per person was limited to 120 VHWs and 60 CHBCs per district. According to the workplan, payments of the incentives was to be done monthly. However, during implementation the PR in consultation with the SRs agreed to make the payments quarterly to ease logistical pressures. This was supported by the CHWs who felt that it was more economically/sensible to receive the cumulative amount than the monthly allowance.4.1.4Adherence to national guidelines and targetsThe training that was provided to CHWs was in-line with the national curricula for both the VHWs and CHBCs. While the curriculum for VHWs is expected to be delivered over a period of 8 weeks, the GF only provided funding for a three week training period. The two week training period required for CHBC training was adequately provided for under the grant. Although the general national guideline for VHW coverage is 1 VHW per 100 households there is no well defined number of VHWs or CHBCs required in the country. Coverage in the field is going to as high as 1 VHW to 500 households. The Health Transition Fund estimates the required number of CHWs at 17,000. The CHW programme had planned for 11,160 but then trained 11,514.The VHW programme in the country is considered voluntary and therefore no allowances were provided for. However, during the design of the CHW programme there was an initiative to improve the incentives received by the CHWs in appreciation of the work they were doing. It was at this point that the $15 per person per month was introduced. This has since been included in the draft Village Health Worker national strategy.The standard package for the VHWs includes 2 uniforms amongst other provisions such as bandages and pain killers while that of CHBCs include a CHBC kit. The CHW programme provide for the uniforms as well as the CHBC kit but did not provide the VHW complete package.4.2Capacity of CHWs to implement planned interventions4.2.1Training requirementsThe CHWs that participated in the PLA exercises reported that, prior to the training, their knowledge levels were very low particularly in the areas of TB, HIV and AIDS and malaria (estimated at between 10 to 20 percent). The reasons for this low level of knowledge were that they felt they only had superficial and out-dated information on the health issues or diseases before, with some even confessing that their interpretation of the little information they possessed presented potential harm to their family and community. A particular example that was cited related to the use of cow dung in the management of burns. The main area of significant improvement cited by CHBC caregivers was their ability to provide palliative care to PLWHAs and their families. One of the nine modules of the harmonised CHBC Training curriculum is focused on palliative care. The training itself was reportedly focused on palliative home-based care. As such the caregivers felt they were now better able to deal with the other emotional, spiritual and psychosocial needs of their clients in addition to physical pain issues.The CHBC caregivers who received the training demonstrated a good understanding of the concept of palliative care and home based care in general and indicated that despite the decline in terminal cases requiring end of life care amongst PLWHA the skills acquired are applicable from the onset of one’s illness and extend to other non-communicable diseases including cancer, stroke and heart related illnesses. In the absence of direct observation and records of skills assessment, this review depended on the caregivers’ account and key informants including HOSPAZ and ZAN to establish the extent of change in skills amongst the trained (see Annex 6, for more details). Discussants and interviewees provided a communal opinion that there was demonstrable improvement in care giving skills amongst the trained. However, they also emphasised the need for refreshers courses and continuous mentorship as well as extending the training to the management of other common illnesses.4.2.2Appropriate skills-mixThe skill acquired by the CHW acquire determined by, among other things, the training received. The CHBC were trained according to the full curriculum designed by the MoHCW and therefore they were adequately equipped for the intended purpose. On the other hand, the training given to the VHWs was delivered in 3 weeks even though the full curriculum should ideally, be covered in at least 8 weeks. Although different partners have augmented the training to various levels, there still remains a significant gap in the skills of the VHWs to fully provide the requisite services at optimal level. This skills gap has further been widened by the introduction of new focus areas on maternal, new born and child health issues which are the focus of the HTF. The VHW curriculum is currently under review to incorporate this dimension. Additional training will be required to equip the VHWs with the appropriate skills in this regard. Even when the CHWs receive the full initial training, subsequent refresher training will be required to continuously match their skills with new requirements.While the CHWs are expected to do more of preventative work than curative, there is a general feeling that these cadres can be effectively involved in some initial stages of the curative process. Frequently mentioned areas include sputum collection as well as testing for malaria. The MoHCW has since started training CHWs in the use of RDTs to facilitate treatment of malaria in the communities. These skills should be considered for inclusion during the review process of the curriculum.4.2.3Adequacy of supervision of CHWsThe success of CHW programmes hinges on regular and reliable support and supervision. Continuous supervision diminishes the sense of isolation that CHWs usually experience in the field and helps to sustain their interest and motivation to do their assigned tasks. In the areas visited, there was no standard checklist used to guide the supervision of VHWs. The interaction of the VHWs and their supervisors was only limited to monthly meetings which was not adequate to mentor the VHW in performance improvement. In some areas, the nurses did not have adequate information on how and when the incentives were provided. This posed challenges in supervision as the VHWs felt their supervisors were letting them down. It was also noted that there was limited on the-job supervision because of transport challenges. EHTs in some wards were providing support and supervision to the VHWs because of their regular contact and access to motorcycles and bicycles. However, transport still poses a challenge as the vacancy rate for the EHTs is high. Lack of systematic involvement of cadres from other MoHCW departments in CHW supervision was said to be due to exclusion of these departments during training of ‘Training of Trainers’ on the CSS programme which involved nursing personnel only. It was however later realised that the VHW cadres would not be adequately supervised without involvement and guidance from other departments. Currently other specialised departments, including the Departments of Community Medicine and Epidemiology respectively are now involved in the training of the cadres.The supervision of CHBCs is mainly provided by the NGOs and CBOs in addition to their monthly meetings with the health professionals. For example, district personnel from FACT in Makoni District were reported to conduct supervisory home visits with the community caregiver supervisor (also a CHBC and community based) to check on patient care. The approach, though realistic in addressing coverage, was observed not to offer adequate mentorship support to each of the trained CHBC caregivers, as there was no evidence of group mentorship or additional follow-up to the other trained individuals. The monthly meetings with the health professionals are largely feedback oriented in which the CHBCs share and discuss their report with the health professionals with minimal skills based supportive supervision.4.2.4Adequacy of logistical supportEvery VHW affiliated to the nearest health facility in her/his catchment area, and is expected to collect/replenish basic supplies whenever there is a need. The basic supplies include pain medications such as paracetamol, eye ointment, vitamin tablets, betadine and bandages. During the field visits it was established that some of the VHWs have not received a replenishment of their supplies for a long time due to the unavailability the necessary consumables at the nearest health facility. Of the 12 VHW teams assessed, 11 had stock-outs of the basic medications and medical supplies for their work. Dumbamwe clinic in Makoni district was the only facility, which reported having recently provided some supplies to the VHW team, but again they reported having had a stock-out from January to March 2012. In most rural clinics, the VHWs would only receive supplies if their local clinic had these in excess. Therefore the VHWs could not do their job properly and this adversely affected the community’s perception of their effectiveness in delivering health services due to the lack of supplies. 4.3Coordination and communication between organizationsAs noted earlier, the VHW programme was revitalised at the height of Zimbabwe’s socio-economic crisis to deal with the cholera outbreak as the health system was not capable of reaching out to every corner of the country. During this crisis, as in others, the UN agencies restructured themselves to support the country response. With the WHO in lead, coordination of the VHW activities was more intense, sometimes being as frequent as bi-weekly coordination meetings attended by all partners and representatives from the provinces and the districts. Reports from field activities were read and strategies agreed to deal with the most crucial issues expeditiously. That way, all people were involved and informed on the goings-on, and all levels of management, the provincial, district and local health facility levels were kept informed and involved. In order to achieve a more holistic and better capacitated community cadre, there is a need for involvement of the nursing, environmental health and health promotion sections within the MoHCW. This would involve participation in development of training curricular, provision of guidelines and ensuring adherence to the set standards of community health service delivery. It also entails monitoring of progress through support supervision, sharing field reports and arriving at consensus in taking the necessary corrective measures. This kind of coordination needs to be institutionalised within the MoHCW, and replicated at the provinces and districts, the levels responsible for decentralised health service delivery. Vertical coordinationThe evaluation found that at each health facility there was a nurse in-charge of the CHW who reports to the District Nursing Officer (DNO) in-charge. The DNOs report to the PNOs who in turn report directly to the Director on Nursing at the National level. However this seemed to be more or less a vertical approach and a preserve of the nursing department as the reporting lines did not include the Health Executives and their teams at the district and provincial levels. At the national level the reports and operational management of the CSS programme fell directly under the Director of Nursing with little evidence of involvement of the Health Promotion and Environmental Health departments. Naturally representatives of the CSS programme were required to attend the CCM Health Systems Strengthening sub-committee meetings both to share their progress reports and get guidance on the way forward but evidently this was not happening as they hardly attended these meetings and their progress reports were rarely shared at these meetings. It was also observed that the available training materials were heavily biased towards nursing due to lack of involvement of all the necessary stakeholders such as Health promotion, Environmental health and other departments in development of crucial VHW training curricula, manuals and materials. Provincial and district coordinationThe limited awareness of the CSS programme activities by the personnel at provincial and district levels had its toll on the effectiveness of the programme with no standard VHW guidance materials or mechanism for involvement in support supervision. At the rural health facilities the face of the health care system and the nearest centre for support to these VHW, the nurses’ in-charge of the CSS programme were not even aware of the schedule for payment of incentives to the CHWs. There was lack of prioritization of support visits to the working places of the VHWs, let alone involvement of the EHT whose work is community based and they therefore needed to work closely with the CHWs to support over 75% of their community work. There was also lack of aggregation, analysis and onward transmission of VHW reports from health facilities which brings into question the design of the overall project, as performance of the VHWs is not monitored or reviewed at any level of the health system except for that of the CHBCs. Nobody seemed to be aware of the strategic direction the CHW programme was taking. When contacted some of the nursing staff said they actually held several coordination meetings (i) national level meetings with PNOs, (ii) PNOs visiting districts to assess the VHW situation, and (iii) the DNO and other nurses visiting the health facilities to assess the VHW situation at the health facilities. Reports from these visits were sent directly to the Department of Nursing and not shared at all the levels. Cross departmental coordinationThe Directorate of Environmental Health personnel expressed ignorance of the activities implemented under the CSS programme although they felt that they should be closely involved since 75% of the VHW’s work is preventive and therefore heavily dependent on support and guidance from the Environmental Health Department. They said supervision visits to the VHWs should have been a joint effort between the EHTs and the nurses from the health facilities so that all aspects of the work of VHWs could be supported to ensure performance improvement. They attributed the lack of support CHW supervision visits by nurses to the predominantly preventive work the VHWs did within the communities which had very little to do with nursing. There were fears the VHWs were only functioning at less than half their capacity as the technical guidance on preventive services such as hygiene, nutrition, food security and related issues were not being emphasised due to marginalization of the Environmental Health Department whose structures are present country wide though some are currently not on the Government payroll. 4.4Facilitating and inhibiting factors in implementation of CHW programme4.4.1Facilitating factorsCommunity participation, involvement and ownershipCHW programmes are governed and owned by communities. The community plays a significant role in the selection of CHWs as well as in providing community level accountability platforms. CHWs were accountable to the communities that selected them. The CHWs in most wards appreciated the receptive nature and taking on board recommendations they gave to the community. TrainingThere is a broad based training curriculum developed by the MoHCW for the VHWs and CHBCs to facilitate their integration in their roles. There is an integrated VHW training curriculum and the harmonised CHBC training curriculum (see Annex 4&5). The complete curriculum developed for VHWs training should take them a minimum of 8 weeks of training. Ideal training will involve 8 weeks of classroom training, another 8 weeks of field practicals and a final 4 week period of theoretical training. The provision of training to the CHWs was seen to enhance the knowledge, skills and overall capacity of the cadres in performing their work.UtilisationThe CHW are recognised and utilised by the communities as evidenced by reports made by community leaders, reports submitted to their respective CBOs and the RHC on monthly basis. The reports detail the contacts made with the communities on various health related issues. Community members know when and how to approach CHWs when the need arises. Some of the proxy indicators that the CHW play an important role include: increased number of people referred and visiting the nearest health facility for medical attention for various ailments. This indicates that people get to them first before visiting the health workers;reduced number of home deliveries;increased number of women visiting the ANC within the 3 months of pregnancy;increased knowledge levels among community members about certain diseases such as Cholera, HIV and AIDS, TB and Malaria prevention;reduction in stigma and discrimination of PLWHA and even in the general burden of HIV; and,increase in coverage of immunisation. There was a reported decrease in the number of HIV/AIDS related deaths and an increased uptake of partner HIV testing and ART treatment in the areas. The number of individuals undergoing HIV testing had gone up as the CHWs encourage partners of pregnant women to seek the service. This is a contribution to conforming to the Zimbabwe National HIV and AIDS Strategy (ZNASP) promoting multi-sectoral approach to the fight against the HIV epidemic. Reduced HIV/AIDS related stigma and discrimination was reported. The CHWs are also providing medical and psychosocial support to chronically ill patients in the communities.Follow up of TB patients at community level was said to have improved. Improved TB treatment outcomes were reported, with an increased identification of suspected Multi Drug Resistance (MDR) cases. More positive cases of suspected malaria were being identified in the community compared to previously where there was total reliance on nurses at facility level. It was reported that there were less false negative malaria cases identified than before at the facilities. The contribution of the VHW cadre was through education and promotion of the use of insecticide treated nets (ITN’s). Mashonaland West Province was the first to train VHW cadres on the current Malaria drug regimen. Manicaland reported that in 2011 they had no reports of malaria deaths with only a few complications.Monitoring and evaluation There is a standardised recording of cases for the CHWs. The VHWs’ reports are mainly based on the activity reporting whilst the CHBC caregivers record both case registrations and the activity reports. The difference could partly be related to the nature of the VHW work, which is largely community wide rather than case based. However, VHW case registration would still have been appropriate for the specific diseases such as malaria, diarrhoea or the minor ailment cases they deal with. Village Health WorkersThe VHWs’ have a newly introduced reporting format. The reports provide a summary of their activities and client contacts disaggregated by diseases and programme areas such as immunization and nutrition. VHWs submit the reports monthly to the Nurse-in-Charge at the nearest Rural Health Centre. The extent to which the reports are reviewed and analysed by the health professionals and VHWs was observed to be unsystematic varying from facility to facility and largely driven by the initiative of the team manning the facility. Some health professionals interviewed in this review noted that the VHW reports had been useful in flagging disease outbreaks in the community. Community Home Based CaregiversThe CHBC caregivers register their cases using a Case Registration Form whose statistics are collated into a Monthly Reporting Form. In some wards, CHBCs were not submitting their monthly reports to the local clinic and only submitted to the NGOs that trained them. The CHBC reports are discussed during their monthly meetings with the local health professionals. These meetings are held separately from those of the VHWs. Unlike the VHW reports, a caregiver supervisor keeps the CHBC reports. The reports are submitted to the parent organisation (usually NGO or CBO) where they are tallied and submitted into the national HIV and AIDS M&E System/CRIS Database through the National AIDS Reporting Form (NARF). Data for the CHBC component funded by the Global Fund programme is consolidated at District, Provincial and National level through a programme database managed by the Sub-Recipient HOSPAZ. IncentivesThe Global Fund (GF) is providing funding for a monthly allowance to the CHWs of $15. This amount is accumulated and disbursed quarterly. The allowances disbursed through the MoHCW are subject to an administrative levy of $1/month for each VHW paid. As such, the quarterly allowance received by the VHW was $42.00. The CHBCs paid through ZAN receive the stipulated $15 per month without any deductions being effected. It emerged that partners were providing different forms of incentives to the CHWs in different areas i.e. bags, t-shirts, money and other groceries. The irregularities in receiving the allowances were demotivating on the part of CHWs. The two districts visited had each more than 120 VHWs trained while only 120 had been budgeted to receive the monthly allowance from GF. In Chegutu, the district authorities were distributing the allowances evenly while in Makoni the additional CHWs were placed on a waiting the list. The latter was seen to have caused some disharmony between the CHWs receiving allowances and those not receiving even though they were doing the same job. At Dumbamwe Clinic, Makoni district, there were four village community workers and four VHWs supporting the clinic. Only two of the VHWs were trained under the GF, and therefore receiving allowances. Whilst the others recognise themselves as being on a waiting list for receiving both training and allowances they said they were still committed to the good cause of their job, but nevertheless they also had essential needs that needed to be addressed by the health authorities. To compound it all, other implementing partners would come into an area and provide incentives for CHWs for a few months and then leave without coming up with a good exit strategy which would ensure continuity of the programme. It was however reported that incentives for the CHBC’s were more regularly received, and were supported by other partners, and constituted more additional items over and above a monthly allowance of $15 per month. The community and other stakeholders recognised the VHW as a cadre that had more responsibilities than a CHBC, which was reflected even in the selection criteria where literacy skills were highly emphasized in VHW selection compared to CHBC’s. The incentive level for VHW’s may therefore have been set at inappropriate levels, much on the lower side in this regard. RetentionAttrition of CHW was noted to be low, mainly due to death of the members. In Chegutu district, after 157 VHWs were trained by end of 2010, only 7 were lost by the time of this evaluation. The VHW cadre has remained available to undertake their duties whenever necessary despite the on – off nature of the VHW programme. Many VHWs currently operational were first trained in early 2000 – 2002. Although the incentives play a part in motivating the CHW to remain committed to do their work, the major motivator was noted to be the passion to work in the interest of the community. Speaking generally the CHWs confessed there are other extra advantages which seemed to override the incentives as the motivator namely:the fact that they are the first to know of any new health related information before other community members gave them courage and enabled them to utilise the information within their immediate and extended families before they reach the larger community;the VHW position provides opportunities to learn and be recognised in the community. It provides them with a level of invaluable social status;abundant hope – although the incentives are not consistently provided the VHW remains hopeful that they will come. This hope is also supported by their awareness that VHW is not a full-time paid job for which remuneration would be expected on a regular basis;as promoters of health related issues, they also benefit from promotional materials such as hats and t- shirts;self-gratification in providing help in the community.Relationship with the formal health system There is positive indication of integration of the community system into the health system as evidenced by the linkages with the local institutions through supervision and support by local health professionals and reporting at the local facilities. Both the VHWs and CHBCs meet with the local health professionals on a monthly basis during which they submit their monthly activity reports, share their experiences and challenges as well as receive new health information essential for their day-to-day work.4.4.2Inhibiting factorsInadequate training Due to funding limitations, different partners support the training to different extents. While the Global Fund provided funding for three weeks training for the VHWs, UNICEF and other NGOs provided funding for additional training in the two districts visited. The two week training for CHBCs was adequately funded by the GF. In certain wards visited, some VHWs were trained for only 3 weeks, with the entire 8-week curriculum crammed into these three weeks leaving doubts about the uptake and retention of the knowledge passed on in such a way. Inadequate supplies and commoditiesThe health facility staff and community members reported that for a long time the VHWs have been operating without adequate supplies largely due to the broader supply chain constraints which have led to the local health facilities operating with inadequate and irregular supplies. The situation of the CHBCs was somewhat different as they largely depended on the NGOs and CBOs for their supplies which usually came in the form of HBC kits. Challenges were however also experienced, as at times they would also require regular replenishments either from the organisations or the local facilities.Inadequate support and supervisionThe success of CHW programmes hinges on regular and reliable support and supervision. The interaction of the VHWs and their supervisors was only limited to monthly meetings which was not adequate to mentor the VHW in performance improvement. It was however later realised that the VHW cadres would not be adequately supervised without involvement and guidance from other departments. Currently other specialised departments, including the Departments of Community Medicine and Epidemiology respectively are now involved in the training of the cadres.The supervision of CHBCs provided mainly by the NGOs and CBOs in addition to their monthly meetings with the health professionals. The approach, though realistic in addressing coverage, does not offer adequate mentorship support to each of the trained CHBCs. The monthly meetings with the health professionals are largely feedback oriented in which the CHBCs share and discuss their report with the health professionals with minimal skills based supportive supervision.Numerical inadequacyThe effectiveness of VHWs is adversely affected by a number of factors including: the inadequate number of personnel engaged to cover the needs of their communities; the lack of medical supplies and tools to use; and inadequate backstopping support and supervision. Only one of the 12 facilities visited in the field had the ideal ration of one VHW per village with the rest serving 3 or more villages with an average of 100 households.CHAPTER 5: FINDINGS - PROGRAM RESULTS5.1Perception of community members and leaders on CHW programme5.1.1Strengths and weaknessesWhile most of the people encountered during the evaluation study perceived the programme as making a positive contribution to change in the community, the strengths and weaknesses of the implementation process were noted as well (see Table 4). The utilisation of the services provided by the CHW by the community is negatively affected by lack or unreliable supply of medication. In some cases, members of the local community are reported to have lost confidence in the CHW after several failed attempts to seek assistance due to unavailability of the required medication forcing the CHW to refer the clients to the nearest health centre. This was noted particularly in the case clients seeking malaria prophylaxis/ treatment, treatment for headaches and minor injuries which in the past were readily available in the VHW’s tool kit. In other instances, CHBCs were reported to be carrying stocks of materials that are no longer relevant for their clientele such as linen servers. Table 4: The programme strengths and weaknessesStrengthsWeaknessesCHWs providing health education and information to prevent diseases and awareness of available health servicesTreatment and support at community level without having to travel long distancesFees and other facility related costs are avoidedServices provided by those we trustEmergencies can easily be attended to within the communityFacilitating behavior change in hygiene, HIV prevention and health seeking behaviorsCoverage of activities is low due to numerical inadequacy of VHWs and their lack of transportLack of medication and other medical supplies (bandages) to effectively provide treatment, care and support in the community.Inadequate and inconsistent provision of incentives to the CHW.5.1.2PerceptionsPerceptions from the following are missing:RHC staffNurse in chargeDMO and DNOEHTIndicate what was said on what has changed due to presence of CHWs5.2Results of community interventions 5.2.1MalariaFigures 2 and 3 show that the trend in the reporting of suspected malaria cases to the health facilities changed substantial after the CHWs received appropriate training in early 2010. The training was completed in June 2010 and immediately following that period the number of confirmed malaria cases reported rose sharply. Although this also seemed to follow the trend in the rainfall patterns in the country a comparison with the figures shows that many suspected malaria cases are flocking to the health facilities.Figure 2: National Malaria cases and testing trends 2010-2011Figure 3: National Malaria cases and testing trends 2011-20125.2.2HIV/AIDSThe National HIV/AIDS programme continued its efforts to reduce the morbidity and mortality associated with HIV/AIDs through ensuring a well-coordinated scale up on interventions namely HCT, PMTCT, OI/ART, Home Based Care and PLWHA as part of a holistic continuum of care provided through partnership with development partners across the country. The figure below shows marked improvements in number of people accessing these services over the years, the role of the CHWs in mobilising became conspicuous in 2010 as evidenced by the bigger leap in performance in year 2010 when the CHWs completed training and begun actively mobilising communities to seek the services as shown in Figure 4. Figure 4: Trends in routine HIV/AIDS services 2008 to 2011In the last two years Zimbabwe has also carried out HTC campaigns that involved intensive community mobilizations using the CHWs with very good results as can be seen in Figure 5. In all campaign districts the actual coverage with HTC was well above the set targets due to the mobilization efforts of well-motivated CHWs.Figure 5: Planned and actual achievements from the 2011 HTC campaigns in three Districts in Zimbabwe5.2.3TB5.3Cost effectiveness of Global Fund supportThe CSS implementation was not cost effective because the total amount spent was more than the amount budgeted for under the HSS grant as presented in Table 5. Table 5 presents a total budget for all activities of $4,210,136 and an actual cost of $4,335,484.22 realizing an over expenditure of $125,348.22 (3% of budget). Cost effectiveness was compromised by a reprogramming error. The error was such that 5,800 CHWs were targeted for allowances instead of 7,540. This led to a budget shortfall of $313,200. This shortfall was then provided for in Q9 leading to the over expenditure. The positive variance realized under training was due to the non-use of the Year 2 training budget.Table 5: Budget, Expenditure and Variance of the CSS programmeActivityBudgetExpenditureVarianceTraining$1,444,576$1,336,773$107,803Allowances$2,427,760$2,660,911.22.-$233,151.22Uniforms$337,800$337,8000Total$4,210,136$4,335,484.22$125,348.22Source; Round 8, Phase 1 HSS grant documentsEfficiency gains/losses of implementationAs mentioned above, efficiency gains were realized in training activities of CHWs where 354 more CHWs were trained for the same budget. This resulted in the cost of training each CHW reducing from$ 152.38 as planned to $135.90 over the three week training period. This was due to lower unit costs realized through the use of cheaper training venues and use of communal catering services. During implementation the trainers negotiated for lower rates and also used school venues which charged lower rates. Efficiency gains were also realized in the procurement of HBC kits under the HIV grant which were wholly funded by other partners.Efficiency losses were incurred through double funding of training. The Global Fund provided funding for CHWs training through the HSS grant as well as the malaria and TB grants. In total $631,808.89 was spent in training CHWs in malaria prevention (2,863) and TB case management (928). These subjects were also included in the mainstream CHW training curriculum used under the HSS grant.Cost ratio analysisThe cost analysis was performed by comparing the estimated ideal and actual cost of maintaining one CHW per annum. The ideal costs are the estimated cost of providing the minimum package for effective service delivery by a CHW. The actual costs are the costs incurred by the Global Fund in maintaining each one of the 11,160 CHWs in Phase 1 of Round 8. The evaluation has shown that a CHW would on an annual basis require a minimum of eight weeks of initial training, annual refresher training, two uniforms, bicycle and maintenance costs, allowances, basic kit and administrative fees. Table 6 shows the comparison between the estimated ideal and actual of maintaining one CHW per annum.Table 6: Cost ratio analysisCost CategoryAverage Cost (US$)Actual Cost (US$)Direct costTraining 449168Uniforms1515Allowances180180Bicycle900Bicycle maintenance55Kits and replenishment800Sub Total814368Indirect costsAdministration costs2121Total costs835389RatiosDirect: Indirect costs39:118:1Average: Actual package2:1Notes:Global Fund supported three weeks of training whilst according to the MoHCW complete training would take more than 20 weeks. We have however used a minimum of eight weeks training to compute the estimates.The GF did not fund bicycles and CHBC kits during Phase 1 of Round 8.The direct to indirect cost ratio (18:1) shows that for every $18 provided by GF, $1 was used to fund administration cost. The estimated average direct to indirect cost ratio was 39:1. The comparison between ideal cost versus actual cost ratio shows that GF provided about 46% of the required funding to maintain one CHW. The direct to indirect cost ratio show that for every $18 funded by GF, $1, which represents 5.6% was provided to fund administration costs against an average cost of 2.6%. This means that the GF programme incurred higher administration costs as a result of the limited budget. The reason for the variance was that training at inception was reduced from eight to three weeks and HBC kits were provided by other development partners.CHAPTER 6: SUMMARY FINDINGSProgram design and qualityThere is strong evidence that the programme was relevant and appropriate in supporting the Primary health care approach anchored on community involvement and participation in improving awareness, access and utilization of health services. At all levels of the systems, there was appreciation of the importance and necessity of the work of CHWs in supporting the health system, given the general agreement that the CHWs were contributing positively towards achievement of planned health outcomes. Generally, the current design of the CHW component can be sustained as evidenced by overall commitment through adoption and incorporation of community based approaches into the strategic plans.EfficiencyThe programme was cost effective in as far as more CHWs were trained than planned, in reducing the distance the community travelled to seek treatment and this seemed cheaper in terms of transport cost, time costs and also opportunity costs. It was also highlighted that there was a reduction in the number of home deliveries and increase in health awareness as a result of the work that the CHWs in the two districts visited during the study. The programme demonstrated efficiency during training of CHWs as more CHW were trained than planned. EffectivenessThe programme was effective in ensuring that there was a trained community cadre who was to be supported to provide both preventive and curative health services. The CHWs were reported to be enthusiastic and actively involved in providing health services in their communities with the VHWs covering many more disease components than the CHBC who were mainly inclined towards providing HIV/AIDS services. However the effectiveness of the CHWs was affected by their numerical inadequacy, and inadequate support in terms of supplies, incentives, support, supervision and mentoring. Another aspect noted to affect the overall effectiveness of this programme and indeed limited organizational learning efforts was the lack of integration of the VHW reporting (except for some aspects of the TB programme) into the HIS resulting in non-transmission and non-use of VHW performance data at all levels. Potential impactAlthough no direct causal relationships could be drawn between the HIV and Malaria programme results with the CSS intervention, there are indications that the intervention could have contributed positively to the overall outcomes of the disease components.SustainabilityAlthough currently the Government of Zimbabwe is still facing liquidity challenges as the economy undergoes the recovery process, there are indications the initiatives supported under CSS programme will be sustainable. Therefore, in the short and medium terms, donor funding will be critical in sustaining current efforts in supporting the Health System in general including the CSS programme. Incentives such as allowances, uniforms and bicycles are necessary to boost the intrinsic motivation of the CHWs even after GF support.CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS7.1Conclusions7.1.1Programme designThere is evidence that the programme was relevant and appropriate in supporting the PHC approach anchored on community involvement and participation in improving awareness, access and utilization of health services. Generally, the current design of the CHW component can be sustained as evidenced by close linkages with existing structures within the MoHCW and the use of familiar technologies. However, in the short to medium the funding of the initiatives will rely on substantial support from development partners until the national economy has recovered to allow for the collection of significant revenues through the fiscus.7.1.2Programme implementation7.1.3Programme results7.1.4Potential impactImpact prospects in the long term are expected to be very good given the significant contribution to disease prevention at family and community levels. In the short term the interventions made have had an impact on both the HIV/AIDS and malaria programs by facilitating mobilisation of community members to participate in awareness campaigns.7.1.5SustainabilityAlthough currently the Government of Zimbabwe is still facing liquidity challenges as the economy undergoes the recovery process, there are indications the CHW programme will be sustainable. However, in the short and medium term, support provided by development partners will be critical in sustaining current efforts in supporting the Health System in general including the CSS programme. The provision of incentives such as allowances, uniforms and bicycles will be necessary to boost the motivation of the CHWs even after the termination of GF support.7.2RecommendationsHarmonisation and standardization of trainingThere is need to have one standardised training manual for the different groups of CHWs and this should be based on the harmonization of the integrated VHW and CBHC training modules. There should be a minimum training package for all community health workers, which should be developed in consultation and active involvement of all the relevant departments namely Environmental Health, Nursing, Health Promotion, MCH, HMIS to name but a few. There need to have a standardized training model that takes cognisance of minimum training package and has built in mechanisms for on-going supervision, mentorship and refresher courses. This model should lay out the roles & responsibilities of different players including the CHW, and specify timelines for conducting mentorship, supervision and refresher trainings. An annual mapping exercise should be conducted that provides for the identification of CHWs by District, contact Health facility, level of training, community of responsibility, and schedule of incentives to be received and/or received to date. This will provide the basis for determining the numerical adequacy of CHWs in a given geographical location as well facilitate planning and coordination of training, support supervision and provision of incentives. It is envisaged that harmonization and standardization of the training for of the VHW and CBHC training packages would contribute to improvements in numerical adequacy of the CHWs. It is also hoped that this mapping exercise would also identify who is doing what, where in terms of partner support for CSS so that further efforts can be directed to ensure equity. Incentive packageThere is need for a standardised incentive package across the CHWs, and improve transparency and communication around the incentives vis-à-vis commensurate facilitation for CHW workload.Procurement and supply management of pharmaceutical and medical productsThere is need to strengthen the overall supply chain systems to ensure reliable and adequate pharmaceuticals and supplies for health facilities and taking into account the needs of the CHWs in the area. Supervision, support and mentorshipThe current support for support and supervision should first and foremost emphasise frequency of support visits from the focal health facility to the CHWs in their workplaces. Deliberate efforts toward balancing the interactions of both the nurse and the EHT in supervising the CHWs will go a long way in improving the technical capacity, scope of both preventive and curative interventions as well as the quality of services provided by the CHW. There is need for supervision checklists and means of documentation to ensure follow up and continuous quality improvement. Monitoring and EvaluationThe CHWs should be regularly and more reliably provided with registers and simplified summary reporting forms. The HMIS and DHIS should be revised to provide sections for CHW reporting. A comprehensive M&E framework and system that includes a set of indicators on provision of necessary inputs, CHW service coverage, and means of measuring performance the CSS programme should also be developed.CoordinationThere is need for a shared understanding of the results the CSS programme seeks to achieve in order to improve health service delivery in the country (strategies, goals and objectives), as well as promote clarity and commonality of purpose among the key user departments of the CHW cadre. Given the cross-departmental and integrated management nature of the CSS programme, there is need to separate the strategic and operational functions of the CSS programme management through establishment of a ‘home’ to coordinate the routine operational and administrative affairs of the CSS programme. Whatever department/office is chosen to coordinate the CHW programme, it must demonstrate ability to satisfy the criteria of being (a) open and accessible by all the relevant MoHCW departments/divisions/programmes, (b) seek to be accountable to all stakeholders in CSS, (c) have and implement a jointly developed, time-bound and costed work-plan using a known results framework that can be easily monitored by all, (d) fostering organizational learning through submission of regular reports for review by all stakeholders, (e) striving to empower and enable functionality of the decentralised structures of service delivery to coordinate CHW efforts at all levels, (f) be headed by a dedicated fulltime coordinator who is accountable to all stakeholders, reports to a team of directors/deputy directors drawn from the nursing, environmental health, health promotion, any other MoHCW sections and major development partners deemed necessary to provide guidance to the further development of the VHW strategies, and (g) be an active member of the CCM HSS sub-committee. These efforts should be emulated at provincial and district levels through quarterly performance review meetings involving all stakeholders, including review of reports on the activities and outputs of the CHWs in the communities on, and effectiveness of support, supervision and coordination of CSS work, amongst other issues at focal health facility level. Sustainability and options for continued fundingThe Government is encouraged to continue increasing its allocations and disbursements to the programme from the current 6.7 % towards 100% of total need in the long term. We further recommend that incentives such as allowances, uniforms and bicycles be considered a necessary component of the CSS programmes at all times. The Global Fund is encouraged to provide funding for the component through one grant, the HSS grant. At the moment funding for the component is provided through all the four grants (as shown in Annex 7, Financial Gap Analysis). All training for CHWs should be coordinated centrally.ANNEXESAnnex 1: Terms of Reference for the Zimbabwe CSS EvaluationBrief Background: The Village Health Worker programme in Zimbabwe dates back to 1981, when it was introduced as part of the comprehensive primary health care approach. In 1984, the ownership was transferred to Ministry of Women Affairs, and the VHWs were renamed as Village Community Workers., with the focus on development and income generating activities. The VHW programme was reintroduced in 2000, under the Ministry of Health (Nursing Directorate), to revitalize and focus on health issues and serve as the centre of community health services. The National Strategic Plan 2009-2013, focuses on established and retaining trained cadre of Community Health Workers for provision of preventive, promotive and curative services.Global Fund and Community Health worker Programme: A decade of high inflation, severe economic decline and rising poverty led to the departure of skilled health staff and the deterioration of infrastructure, which have seriously compromised efforts by the government of Zimbabwe and its international partners to provide universal access to basic health services and combat HIV, tuberculosis (TB) and malaria. The goal of the Round 8 Cross-cutting HSS programme is to achieve a strengthened and more effective health delivery system through retention of health workforce, strengthening community health systems and the scale-up in community programs for the three pandemics.The Community Health Systems strengthening component included allowances, and purchasing bicycles, uniforms and other necessary working material an average of 5 community health workers per ward in rural and urban districts. It was estimated that were on an average of 180 community health volunteers per district, and funding would be based on this number which is also seen as the minimal number required which can ensure an effective impact. The country targets are to have 1 VHW per 100 households. A total 6,332 VHWs had been trained by February 2006, leaving a national gap of about 20,000 for this cadre. The intervention would support over 11000 CHW including the VHW, and bringing in other CHW groups trained by various partners as CBD and CHBC. The supervision of CHWs was planned to be strengthened through support to the district health staff that will benefit from health worker retention program also supported under the current grant. The CHWs were also to benefit from training and enhanced supervision in specific skill and disease areas proposed in the three disease component bids, as well as by current and future support from other partners.The duties of a VHW include treating minor ailments, providing medical and psychosocial support to chronically ill patients at home, following up patients, identifying problems in the community and advising the rural health centres accordingly. They are supposed to work for 2-3 days per week. However, due to the increasing burden from HIV and AIDS and TB, the job of the VHWs has now become almost full time. Apart from increased work load, these critical cadres are also faced with a number of other challenges, including (i) inadequate allowances – at the moment they get less than 1 USD per month; (ii) Lack of transport and therefore inability to visit all people in need within their catchment areas; (iv) Lack of uniforms and resource materials, including stationary for record keeping and (v) Limited of supportive supervision.The Round 8 grant, had a total proposed budget for USD 9.3 million over 5 years (USD 4 million in Phase 1). During the Phase 2 assessment, the Phase 2 Panel recommended that the Principal Recipient shall submit a report, in form and substance satisfactory to the Global Fund on the current CHW work stream in order to (i) measure the return on investment (cost-effectiveness analysis), and (ii) to identify opportunities for increasing efficiency which would allow for supporting the CHW work stream with less expenditure.Key Objectives:Assess if investments in CHW programs, has improved the effectiveness, efficiency and results of the HIV/AIDS, TB and malaria programs in Zimbabwe.Provide a comprehensive analysis of potential options for the improving efficiency and effectiveness of CHW programme, with clear recommendations for preferred options for continued funding.Key Evaluation Questions:Program Design:Is there any evidence that programs (HIV, TB, malaria and maternal and child health) have incorporated community based approaches through CHWs into their program strategies? Is there evidence to suggest that CHWs have participated in and contributed to the three disease control program, and MNCH? Is there evidence to suggest that the CHW component as currently designed can be sustained beyond the Global Fund investments?Program Implementation:Have the community health approach interventions been implemented as intended?Adherence to work plan: service package, delivery approaches and adherence to national guidelines/procedures, target populations and subgroupsIs there adequate capacity (trainings, and appropriate skill-mix) to implement the planned interventions? Is there sufficient coordination and communication between various organizations implementing community strengthening programs?What are the facilitating and inhibiting factors in the field implementation of the CHW program?Are the health worker skills adequate to meet the increasing scale and scope of the community respond for the 3 diseases?Program Results:Have the CHW program contributed to scaling-up the program strategies/ interventions?What have been the results of the community interventions on HIV, TB and malaria diagnosis and treatment, referral and follow-up, linkage between home/community-based care with facility care and provision of care and support?What are the enabling and limiting factors for achievement of results?Is the CHW program supported through Global Fund grant cost-effective? What is the ratio of direct to indirect costs for maintaining each CHW; what is the cost ratio for delivering package of desired services as envisaged and actual based on results; Methodology:Mixed methods approach. Review available secondary CHW program and grant data – on investments, outputs and results. Key informant interview, to understand challenges and opportunities for maintaining and scaling up the program.Annex 2: ReferencesThe Zimbabwe National Health Strategy (2009-2013); Ministry of Health and Child WelfareNational Community Home Based Care guidelines; Ministry of Health and Child Welfare, 2009The Zimbabwe National HIV/AIDS Strategic plan 2006-2010; National AIDS Council, 2006The National Tuberculosis Strategic Plan 2010-2014; Ministry of Health and Child Welfare, 2010The National Malaria Control Strategy 2008-2013; Ministry of Health and Child Welfare, 2008The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers, January 2007, Utah Lehmann and David Sanders, School of Public Health, University of the Western Cape.The draft National Village Health Worker StrategyThe Round 8 HIV, TB, Malaria Q1-Q8 PUDRsA situational Analysis on the status of Women’s and Children’s Rights in Zimbabwe 2005-2010; A call for reducing disparities and improving equity, UNICEF, GOZ,The Zimbabwe Health Sector Investment case 2010-2012, MoHCWThe Health Transition Fund for Zimbabwe, December 2011, MoHCWHealth Transition Fund for Zimbabwe, Year 1 Implementation Plan, MoHCWThe Village Health Worker Training Manual 2011, MoHCWAnnex 3: Criteria for selection of VHWsMaturity age (25 years and older)A mature married residence of the village (woman or man are preferred for stability in the village)Able to read and writeGood reputation in the villageA good communicator and mobiliseA well respected person in the communityInterested in health and development issues (a role model)Willingness to work in the community and on voluntary basisSomeone who is able to maintain confidentialityNB: i) Single females are less favoured as they will sooner leave the village upon marriage to the husband’s home ii) VHWs are recruited to replace those who become inactive or are older and unable to continue with VHW activitiesAnnex 4: Training curriculum for VHWsNoTopicPageCHAPTER 1: GENERAL CONCEPTS1.1Primary Health Care51.2Community as a Client51.3Communication81.4Communication Strategies for Effective Health Education and Promotion181.5Health Promotion191.6The relationship between Village Health Workers and other Community Based Practitioners211.7Team Approach1.8Advocacy, Social Mobilization and Programme Communication221.9First Aid251.10Non Communicable Diseases411.11Mental Health and Mental Illness481.12Oral Health531.13Psychosocial Support581.14Community Home Based Care601.15Disability and Community Based Rehabilitation641.16Palliative Care691.17Nutrition721.18Community Based Counseling731.19Eye Conditions781.20Skin Conditions811.21Stigma And Discrimination841.22Hazardous Substances861.23Planning901.24Monitoring and Evaluation911.25Preparation, Conducting and Chairing A Meeting951.26Report Writing971.27Record Keeping971.28Support and Supervision of the Community as a Client by the Village Health Worker981.29Stock Management, Supplies And The VHW Kit100CHAPTER 2: COMMUNICABLE DISEASES2.1Diarrheal Diseases1022.1.1Dysentery1032.1.2Typhoid Fever1042.1.3Cholera1052.2Malaria 1102.3Tuberculosis1132.4HIV/AIDS1172.5Sexually Transmitted Infections1242.6Zoonotic Diseases1272.6.1Anthrax1272.6.2Rabies1292.7Bilharzia1332.8Environmental Health1362.8.1Water Supplies1362.8.2Sanitation1402.9Hygiene1442.9.1Personal Hygiene1442.9.2Home Hygiene1502.9.3Environmental Hygiene1512.9.4Food Hygiene1522.10Community Based Disease Surveillance1542.11Infection Control at Home and Village Level1572.12Discharge Planning Guidelines159CHAPTER 3: MATERNAL, NEONATAL AND CHILD HEALTH3.1Antenatal Care (ANC)1613.2Maternal Morbidity and Mortality1643.3Neonatal Morbidity and Mortality1663.4Malaria in Pregnancy1683.5Labour and Delivery1693.6Postnatal Care1713.7Infant Feeding1743.8Integrated Management of Childhood illnesses1773.9Diseases Preventable by Immunization1813.10Nutrition1913.11Weaning2003.12Growth Monitoring2013.13A Child with Diarrhea2033.14Child Abuse2053.15Reproductive Health2073.16Men and Reproductive Health2133.17Adolescent Reproductive Health2153.18Family Planning2173.19Gender2303.20Abortion2353.21Infertility2373.22Menopause2393.23Andropause2413.24Cancers of the Reproductive Health System242CHAPTER 4: PREVENTION TO MOTHER AND CHILD TRANSMISSION (PMTCT)4.1Prevention of Mother to Child Transmission (PMTCT)2494.2Infant Feeding recommendations in the context of HIV2634.3 Breast Feeding266References273Annex 5: Training curriculum for CBHWsAnnex 6: A Story of Change by the Dumbamwe Clinic CBHC TeamA Story of Change: CHBC Team Dumbamwe Clinic, Nyagumbo Rural Clinic, Makoni District Supported by FACT RusapeWe were trained at different times, some of us were trained as HBC caregivers 2006, 2007 and others 2008 and 2009 by different organisations like GOAL, who are no longer operating here now. We were trained on different things like others were first trained on HIV and AIDS basic facts and how to do counselling and conduct support groups, others were trained on how to conduct home visits and do home based care and others were just Behaviour Change Commutation Facilitators responsible for distributing IEC materials and condoms. Around 2006 - 2007 HIV/ AIDS was a serious problem and many people were bed-ridden and many people were dying. There were funerals all over that neighbours would bury their relatives on a kind of timetable so as to be able to attend the others’ funeral. There was a lot of stigma and discrimination of PLWHA and lack of knowledge and a lot of misconceptions about the disease. Other people preferred consulting traditional healers and faith healers so they would not take counselling serious and kept denying their HIV status.When this programme came through FACT Rusape, we were told they need about 60 people to be trained, so we were selected by the community based on the criteria that we are permanent community members, have good public relations, willing to work for the community and we were energetic, others had some previous experience and some knowledge on HIV and AIDS and HBC. 30 women and 30 men were trained.During the training, we were told that our main job was to provide care and support to the patients directly and also help the primary caregivers with some chores as well as teach them on how to care for their patient. The training was very helpful for us as we learnt how to do the work correctly. At first before training, we:Were not conscious about confidentiality, we would just talk about our clients sometimes and people would avoid us and say the client is sleeping needs a rest just to avoid us because of fear that we will talk about them. Did not know about considering clients’ emotional and spiritual well-being, we just focused on the physical aspectsWere not able to train the primary care givers on how to care and support their patient, so we would just do the work for them and leave. This caused problems for some of the patients, as they would not be assisted in our absence etc.After FACT trained us, we learnt basic etiquette and CHBC: How to get into the household and involve the primary care givers in the care of the patients. We were told that were are secondary caregivers and are not to replace the primary carers as we do not stay there forever. We learnt how to check on how the patient is doing, Help turn the patient, change their linen, feed them, talk to them, encourage them to take medication and so on and so on. If they agree, we also prayed for the patient and sometimes help fetch water, clean the house and yard etc. We were also responsible for identifying and referring patients to the clinic for TB Screening and TreatmentProviding health education information on specific topics such as ART, TB pain medication, nutrition, hygiene Promoting uptake, use of condoms as well as distributing these and other IEC materialsCommunity mobilization to reduce stigma and discrimination of PLWHA, conducting weekly support groupsProviding supportive counselling to persons requiring such and encouraging them to utilise available HIV and AIDS servicesThe training helped us to be effective in doing our work. In terms of knowledge we could say it increased from 1/10 to about 9/10 and capacity to perform our duties was also increased from 1/10 to 8/10. As we undertook our duties, we started noticing that most of our patients were forthcoming and taking up HIV and AIDS services, enrolling on ART and adhering to treatment. Attendance to support groups also increased and we were able to form clubs like now we have soccer clubs for our OVC and some who are living with HIV and have held several competitions where they won soccer kits and boots for the team. Stigma and discrimination of PLWHA was reduced in the community and now there is no more finger pointing and whispering that “wakarohwa nezishiri” “Ariparwendo”, “ndi Code 1”, “ibhazi” kana kuti ane “AIDS”. PLWHIV now remind each other about collection of their monthly drug supplies with statements like “when are you going to juice up”,. People are now knowledgeable about HIV, that it is preventable and manageable. They know each other and solicit support from one another without hiding their HIV status. All this is a result of the work that we have done especially with the support from training and refresher courses that we received from FACT. Right now there is not much work anymore as most clients are mobile and able to do their usual work, there are very few bedridden clients. In fact in most circumstances where there is a bedridden patient it will be someone who came from Harare and very sick with AIDS and ready to die. Our roles and responsibilities have now slightly lessened as we are now mainly o focusing on on-going counselling, adherence monitoring (TB DOTS and new ART patients, encouraging people to use condoms consistently and correctly. We were also distributing condoms and doing community mobilisation to reduce stigma and discrimination, prevention and referrals to clinics for further support. Apart from the training, we also feel that this programme provided us opportunities to learn and help ourselves first before we could reach out to the community, information we learnt was helpful to ourselves, immediate families and other relatives. We got to know first and applied it. The incentives that were also provided for us were also helpful although they are no longer coming these days. We were able to buy essentials like soap, Vaseline, so we could confidently stand in front of people and talk about health and hygiene while looking smart. T-shirts, hats and uniforms also boosted our confidence because people in the community could identify us by these. Our work also came with challenges of transport and incomplete uniforms. We did not have shoes and bicycles but were promised they will be provided. Even though, this did not necessarily deter us from conducting our duties and we are thankful for the support we received. We would however wish to receive the incentives on time and if they could be increased to at least $20 or $30 per month. We can talk about the most significant changes that this programme brought in different ways. At community level, Stigma and Discrimination of PLWHA was significantly reduced as we have already highlighted. This is also shown by the rate at which people are taking up HIV and AIDS services. Annex 7: Facility Based Examples of Battery Scores Before and After the Training (CHWs)Examples of Battery Scores Before and AfterBurnsmack ClinicTrainingBefore3/10After10/10Patakadzidziswa ka, bhatiri rakakwira kusvika 10 bars pa level ya Village health worker nekuti tisati tadzidza taiti Malaria inyongo, tobva tati vanhu ngavatore mishonga yechivanhu inokonzeresa running tummy. “ After our training our battery levels rose to those of the VHWs because before the training we even used to relate malaria with heartburn and even recommended that those who were ill should take herbs that could cause running tummy”We used to also encourage malaria patients to “steam” under the blankets and breathe in the steam from hot water to get rid of the fevers they will be experiencing.Burnsmack ClinicCapacityBefore2/10After7/10Before training we were using general knowledge that everyone in the community had and in some cases our strategies failed because people would die even our own relativesIt’s now about 7/10 because we are practicing what we were taught. It’s not 10/10 because when they trained us they said information changes on daily basis in the health and so we feel that we may be overtaken by events given that its been sometime since we had a refresher course. Msengezi ClinicKnowledgeBefore2/10After8/10Our knowledge levels increased. Before training we used to think TB chirwere chedzinza nekuti chaibata vanhu vose mumhuri imwe chete. After training takaziva kuti TB inotapurirwana sei, saka kana tisina kudzivirira, inogona kubata vanhu vose. Takuziva kuti hembe ne magumbezi anoshandiswa nemurwere we TB anofanira kuwatshwa, mawindo anovurwa uye mushonga akawutora nemazvo TB inorapika. Before the training we used to think that TB is a disease that was family and genetically linked as we used to see family members being affected. After the training we now knew that it is communicable and we aware of the hygiene and treatment requirements in the care and support of TB clients. Msengezi ClinicCapacityBefore3/10After5/10Reasons for low capacity levels:We have other personal HH chores and responsibilities to take care of. During the farming season, we also have to attend to the fields. At the end of the day we are tired and can’t do our village health work effectively. We also have to raise finances for to support our familiesWorkload is too much, we cover large areas on foot and distances drain our energy before we reach many clientsWe lack resources to assist us undertake our roles and responsibilities, e.g. VHW Kits, Rain wear during rainy season when there are usually outbreaks of waterborne diseases. Msengezi ClinicKnowledgeBefore1/10After9/10Msengezi ClinicCapacityBefore1/10After8/10Our capacity is compromised because we are no longer able to treat malaria at community level. Ma referrals hashandi nekuti patient unoitaurira kuti enda ku clinic unotestwa malaria inokuudza kuti hayina mari yekuenda Inotarisira kuti ndimupe mari ye transport ne $1 rekubhadara clinicVamwe vakanzwa kuti kunitestwa vanofunga zve HIV ende havaendi.Annex 8: Evaluation FrameworkEvaluation QuestionsTypes of answers/Evidence NeededMethods for data collectione.g., records, structured observation, Key informant interviews, mini-surveySampling or selection Approach(If one is needed)Data Analysis methods e.g.…MethodData sourcesPROGRAM DESIGNIs there any evidence that programs (HIV, TB, malaria and maternal and child health) have incorporated community based approaches through CHWs into their program strategies?Analytic description of the technical approaches/ strategies and objectives of the programs (HIV, TB, malaria and maternal and child health); evidence of CSS involving established community health workersDocument/ Literature reviewNational Strategic & grant documents, Project theory of change, M&E plan, performance (activity, quarterly, annual, and other relevant) reports; work plans, budgets, financial reports; survey reportsNoneContent analysis and interpretation of qualitative findingsIs there evidence to suggest that CHWs have participated in and contributed to the three disease control program, and MNCH?Analytic descriptions of the entire national and district coordination structures (up to lowest service delivery level), quality of the relationship that exists whether it’s also supportive and mutually beneficialAnalytic description of supportive mechanism for the work of the CHWs, data recording and reporting systems as well as methodologies used in aggregation and forward transmission to the centre; evidence of use of information generated to influence management decisions and refine implementationDocument Review of program documents, periodic performance reports, minutes of performance review meetings Focus Group Discussions with partners, stakeholders, and target groups at district, health facility and Community level. Key Informant interviews (PR, MOHCW (Directorate of Nursing), ZAN and HSS CCM subcommittee) and external informants (partners, stakeholders and target groups at central, district, health facility, and community level).SWOT analysisDisease specific Policy, Strategic Plan, and implementation guidelinesGrant documents District annual performance reportsKey informants from technical side and stakeholders at all relevant levels especially the community levelSampling of districts and communities to be decided upon during development of protocol Sampling of Lower levels health facilities and communities will be done to achieve a balance between the districts and between good and poor performing health facilities/communities. Content analysis and Grounded theory approach for analysis and interpretation of qualitative findingsConsultative meetings, selection, analysis, feedback and verification of ‘Significant Change’ stories Is there evidence to suggest that the CHW component as currently designed can be sustained beyond the Global Fund investments?Analytical Description and critique of Project Theory of Change including 1. design and approaches 2. The decentralized setting of health service delivery. 3. Role of Ministry/Programs & recipient districts in this process and during implementationAnalytic description of the changing political and social environment and the extent to which districts/communities can develop and implement comprehensive and integrated wok plans for HIV, TB, Malaria & other diseases.The extent to which services are provided in an integrated manner in grant supported districts.Establish linkages and/ or main streaming of GF reporting systems with the GoZ HMIS Establish the readiness/preparedness of the district coordination structures to plan for prevention activities against the three diseases beyond GF investmentsEstablish the extent to which GF Round 8 HSS grant has strengthened health facility based and community based referral/service networks that benefit the vulnerable groups Client perspective of the services offered by GF R8 HSS supported health facilities and communities Desk review of program documents and reportsFocus Group Discussions as in No. 2 above Key informant interviews as aboveSWOT analysisMost Significant Change Technique involving project stakeholdersGrant documents as aboveDistrict annual performance reportsKey informants at National, Province, District and Community Sampling of districts to be decided upon during development of protocol Sampling of Lower levels health facilities and communities will be done to achieve a balance between the districts and between good and poor performing health facilities/communities.Content analysis and Grounded theory approach for analysis and interpretation of qualitative findingsConsultative meetings, selection, analysis, feedback and verification of ‘Significant Change’ stories PROGRAM IMPLEMENTATIONHave the community health approach interventions been implemented as intended? Adherence to work plan: service package, delivery approaches and adherence to national guidelines/procedures, target populations and subgroupsComparison of the actual program results against the targets prescribed in the Project Theory of change/M&E Plan/Performance framework (annually)Compare access and utilization of services - pre and post Project intervention Analytic description of the factors that hindered or facilitated the achievement of program results Describe lessons learnt and best practicesSuggest relevant recommendations Desk review of program documents and reportsReview the baseline and periodic performance information collected quarterly and annually against the project theory of change and M&E/Performance FrameworkKey informant interviews as aboveSWOT analysisStrategic and grant documents as in No. 1 Above. District annual performance reports including HMIS (Plus DQA where necessary) for major indicatorsKey informants from the Headquarters, District Field staff, District leaders, disease focal persons, Health facility staffs, Community Health Workers)Sampling of districts to be decided upon during development of protocol and data collection tools and after budgetary considerations Sampling of Lower levels and health facilities will be done to achieve a balance between the districts and between good and poor performing health facilities and communities. Content analysis and interpretation of qualitative findingsAnalysis of performance trends (routine HMIS and program/grant targets) in the sampled districtsIs there adequate capacity/skills among the CHW cadre (trainings, appropriate skill-mix, supportive supervision, logistical support, e.g., communication, transport and tools of trade) to meet the increasing scale and scope of the community respond for the 3 diseases, including MNCH?Compare the actual program results against the targets prescribed in the Project Theory of change/M&E Plan (annually)Compare access and utilization of services - pre and post Project intervention Compare trends in performance of the CHW – pre and post implementation; available supportive mechanisms for the CHWs, and type and frequency of logistics provided to support work of the CHWsAnalytic descriptions of all the district/community coordination structures strengthened by the grant (including involvement of partners and other stakeholders at national, district and community levels; meetings, communication, involvement of communities and beneficiary populations in various project implementation stages)Analytic description of the factors that hindered or facilitated the achievement of program results Describe lessons learnt and best practices Suggest relevant recommendations Desk review of program documents and reportsReview the baseline and periodic performance information collected annually against the project theory of change and M&E FrameworkKey informant interviews as aboveSWOT analysisStrategic and grant documents as in No. 1 Above. District annual performance reports including HMIS (Plus DQA where necessary) for major disease indicatorsKey informants from the above statedSampling of districts to be decided upon during development of protocol/data collection tools; and after budgetary considerations Sampling of Lower levels and health facilities will be done to achieve a balance between the districts and between good and poor performing health facilities. (Time and distance to play role in the final sample size)Content analysis and interpretation of qualitative findingsAnalysis of performance trends (routine HMIS and program/grant targets) in the sampled districts/communitiesIs there sufficient coordination and communication between various organizations implementing community strengthening programs, specifically ZAN’s community cadre and MOH’s Village health workers?What are the facilitating and inhibiting factors in the field implementation of the CHW program (support from community, assistance from health facilities etc)?PROGRAM RESULTSWhat is the overall perception of community members and community leaders of the strengths and weaknesses of CHW program? What has changed in the community due to their presence?Analytic description of the overall perceptions of the key “supply side” actors in Community Health Systems strengthening component, the strengths and weaknesses of the CHW programKey informant interviews with the actors stated in the questionSWOT analysisKey informant from national, district, sub national and community levels as stated in the questionSampling to be agreed alongside that of the districtsContent analysis and interpretation of qualitative findingsWhat have been the results of the community interventions on HIV, TB and malaria program coverage, and access to services (diagnosis and treatment, referral and follow-up services, including linkages between home/community-based care with institutional care and provision of care and support services)?Comparison of the actual program results against the targets prescribed in the Project Theory of change/M&E Plan (annually)Compare access and utilization of services - pre and post Project intervention Analytic description of the factors that hindered or facilitated the achievement of program results Describe lessons learnt and best practicesDesk review of program documents and reportsReview the baseline and periodic performance information collected annually against the project theory of change and M&E FrameworkKey informant interviews as in No. 1 aboveSWOT analysisGrant documents as in No. 1 Above. District annual performance reports including HMIS (Plus DQA where necessary) for major malaria indicatorsKey informants from National, Province, District, Health Facility and community levelSampling as aboveSampling of Lower levels and health facilities will be done to achieve a balance between the districts and between good and poor performing health facilities. (Time and distance to play role in the final sample size)Content analysis and interpretation of qualitative findingsAnalysis of HMIS and other relevant performance trends in the sampled districts/communitiesIs the CHW program supported through Global Fund grant cost-effective? What is the ratio of direct to indirect costs for maintaining each CHW; what is the cost ratio for delivering package of desired services as envisaged and actual based on results?Determination of the direct and indirect costs of the CSS componentDetermination of clients serviced by the CHW at national and local level as selected in the sample. Determination of the standard unit of output (SOU) and other comparative indicesLiterature reviewReview approved budgets, mapping CSS related costs and collate and analyse expenditure reportsComparison with the cost of alternative health services models e.g. Health Facility visits Vis-a-vis seeking care from CHWsProposal and Strategic documents, Project theory of change, M&E plan, activity, quarterly and annual reports; work plans, budgets, financial reports; survey reports, formative KAPB study report, and protocols)NoneContent analysis and interpretation of costs and other quantitative findingsAnalysis of HMIS and other relevant performance trends in the Country and in the sampled districtsAnnex 9: List of people met and summaries of CHWs met in FGDsName of District/ Facility/OrganizationName of person Met / InterviewedDesignationMashonalanad West PHEDr NyamayaroProvincial Medical DirectorMr MarufuProvincial Nursing OfficerMr TomaActing Provincial Environmental Health OfficerMr GongaProvincial Health Services Administrator???Chegutu DHEMr MafukidzeEnvironmental Health TechnicianMs MadondoDistrict Nursing OfficerMr MukoreraDistrict Health AdministratorMs ChisenaAccountantMr ChinembiriPharmacy ManagerMr ManamikeHealth Information SystemMs S RukashaCommunity Health NurseMs MushipeMatron????Branswick Council ClinicMs GonoSecond Sister in ChargeMs MagayaNurse in ChargeMr MwalaNurse Aid????Musengezi Rural Health CentreMr ZhuwawuNurse in ChargeMr DenguGeneral HandMr ChizangaNurse Aid????Selous ClinicMs GomaniNurse in ChargeMs NyakunyadaPCNR NyakurukwaSCNV UsaiwevhuPCN????Mhondoro Rural HospitalG. KarumbwanaActing Sister in ChargeE. MatemeraDistrict Village Health Worker Trainer?????Chikara ClinicN. GoraSister in ChargeMs NhandaraHealth Centre Committee ChairladyW. NyikaHealth Centre Committee TreasurerC. MbenderaHealth Centre Committee member????Watyoka ClinicV. NyamwedaSister in ChargeMr ChabataCommunity LeaderMs MhlauriCommunity Leader?Manicaland PHEMs ChikukwaProvincial Nursing OfficerM. NyamasokaZAN MutareS. HlatywayoNAC ManicalandMr KuparaNAC Manicaland????Makoni DHEMs BenzaDNOMr NgwaruDistrict Health Administrator?Masvosa ClinicE KutyaNurse in ChargeMr MasvosvaCommunity leaderMr ManyumwaCommunity leaderMr JacksonCommunity leader???Matsika ClinicMs ShamuSister in ChargeMr D GumunyuCommunity leaderMr C. MazivisaCommunity leader???Dumbabwe Council ClinicMs NyamutswaNurse in ChargeMr M MadzivaCommunity Leader???Morris Nyagumbo Memorial ClinicMr NyamandeCommunity LeaderMs E. MagabaWard Aids Committee???UNICEF?Venue: UNICEF BoardroomDr Aboubacar KampoChief, Young Child Survival and DevelopmentDr Assaye KassieHealth Manager???WHO?Venue: WHO BoardroomDr Custodia MadhlhateWHO Resident RepresentativeDr S. MidziWHO???MoHCW??Dr BaseraGlobal Fund Grants Coordinator, MoHCWMr G.T MangwaduDirector, Environmental Health Services, MoHCWMr D. RodrickDeputy Director, Environmental Health Services, MoHCWMs ChasokelaDirector, Nursing responsible for CSS, MoHCWMs J. SiveregiDirector, Zimbabwe AIDS Network (ZAN)Ms D. ManyararaCHBC Coordinator, ZANMs J. MusengiHOSPAZMs C. MarisaM&E Officer, HOSPAZMs C. ChivodzeHOSPAZMr G. MandindeFinance Manager, ZANPR/ UNDP Feedback members available June 13, 2012; Venue UNDP GF PR BoardroomNameOrganisationI. FortesUNDPN. MujuruUNDPP. MukwezaUNDPN. MukuteUNDPS. MusungwaUNDPM. DedaUNDPCCM HSS Sub-Committee members available June 13, 2012; Venue MoHCW 4th Floor BoardroomNameOrganisationMs T Shoumilina UNAIDS (Chair)Dr S Midzi WHOMr. A PhiriZANMs. J Mudyara MOHCWMr. E Boadi UNDPMrs. G R DeteSATMs. C Marisa HOSPAZMs. C ChivodzeHOSPAZMs. J MusengiHOSPAZMrs. T Ndori-Mharadze USG/PEPFARMrs. P ChonziHSBMrs. L MajongaMOHCWMs. I Fortes UNDPMs. C ChasokelaMOHCWMr. N MukuteUNDPMs. T Westerhof PPAATDr. C T BaseraMOHCWOffice of the Director Environmental Health; June 14, 2012Mr. MamwaduDirector Environmental Health, MoHCWMr. Roderick TysonDeputy Director Environmental Health MoHCWSummary of people involved in community interviews in Chegutu DistrictName of ClinicVHWsCHBC Givers #of People in FGDMalesFemalesMalesFemalesBranswick Rural clinic25007Musengezi Clinic12003Selous Clinic05005Mhondoro Rural Hospital17008Chikara Clinic242513Watyoka Council Clinic060410Total FGDs =7Summary of people involved in community interviews in Makoni DistrictName of ClinicVHWsCHBC Givers# of People in FGDMalesFemalesMalesFemalesMasvosva Clinic060814Matsika Clinic01023Katsenga Clinic03014Dumbamwe Council Clinic0461222Nyagumbo Clinic026715Makoni Rural Hospital-----NB: At Makoni Rural Hospital no FGDs were done with VHWs and CHBC due to logistical issues. However discussions were done with the local leadership and health workers present. Discussions were done with 6 village heads and one chief’s representative. Interviews were done with two nurses to discuss the progress and challenges of the CHW programme within the catchment area of the hospital. ................
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