How Do Community Health Workers Contribute to Better

How Do Community Health Workers Contribute to Better

How Do Community Health Workers Contribute to Better Nutrition? Zambia About SPRING The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project is a five-year USAID-funded Cooperative Agreement to strengthen global and country efforts to scale up high-impact nutrition practices and policies and improve maternal and child nutrition outcomes. The project is managed by JSI Research & Training Institute, Inc., with partners Helen Keller International, The Manoff Group, Save the Children, and the International Food Policy Research Institute. About APC Advancing Partners & Communities (APC) is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-12-00047, beginning. APC is implemented by JSI Research & Training Institute, Inc., in collaboration with FHI 360. The project focuses on advancing and supporting community programs that seek to improve the overall health of communities and achieve other health-related impacts, especially in relationship to family planning. APC provides global leadership for community-based programming, executes and manages small- and medium-sized sub-awards, supports procurement reform by preparing awards for execution by USAID, and builds technical capacity of organizations to implement effective programs. Disclaimer

This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-11-00031 (SPRING), managed by JSI Research & Training Institute, Inc. (JSI). The contents are the responsibility of JSI and do not necessarily reflect the views of USAID or the United States Government. Recommended Citation SPRING and APC. 2016. How Do Community Health Workers Contribute to Better Nutrition?: Zambia. Arlington, VA: Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project. SPRING JSI Research & Training Institute, Inc. 1616 Fort Myer Drive, 16th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: [email protected] Internet: www.spring-nutrition.org How to use these slides We invite in-country stakeholders to use this information to: Identify which nutrition-related services CHWs can provide, according to policies; Prioritize and/or reassign responsibilities to

avoid overburdening CHWs; Build a stronger foundation of policies, tools, and systems for CHWs to conduct their work; Plan additional support to CHWs; Design and conduct other in-depth assessments of community nutrition programs; Inform program implementers to strengthen community health interventions. This product was developed using information collected by APC, with input from SPRING, through a desk review of existing policies and documents related to community health systems. Due to the diversity and magnitude of community health programs in a given country, we collected information based on country policies/strategies that comprise the key areas of a community health system and not the realities of program implementation. Due to funding and timing, we focused on national public sector programs, and only when possible, captured community-based private sector health programs operating at scale. In Zambia, nutrition-related health issues persist. According to most recent data, stunting remains a major challenge in Zambia. 58 %

children under 5 49 53 46 40 1996 1999 2002 2007 2013 29% of women of

reproductive age have anemia That means 868 thousand Zambian women have a critical micronutrient deficiency (2011) Anemia also persists as a major issue for Zambias children. 66 % children under 5 1996 60.7 1999

Source: World Bank Databank: 58.2 2002 58.5 2007 only 57.7 2011 10.5 % of children 6-23 months are age-appropriately breastfed and fed the minimum dietary diversity

and minimum meal frequency (2014) We know evidence-based, cost-effective interventions can improve nutrition outcomes. It is estimated that the following 10 evidence-based, nutrition-specific interventions, if scaled to 90 percent coverage, could reduce stunting by 20 percent and severe wasting by 60 percent. Management of severe acute malnutrition Preventive zinc supplementation Promotion of breastfeeding Appropriate complementary feeding Management of moderate acute malnutrition Source: Bhutta et al. 2013.

Periconceptual folic acid supplementation or fortification Maternal balanced energy protein supplementation Maternal multiple micronutrient supplementation Vitamin A supplementation Maternal calcium supplementation Studies have demonstrated the effectiveness of community health workers in achieving demonstrable health benefits directly related to the Millennium Development Goals (MDGs), including reducing child malnutrition and both child and maternal mortality. - Perry and Zulliger (2012)

Community health workers play a critical role in providing these proven, evidence-based, cost-effective interventions. By making basic primary care available at the community level, CHWs make it possible for women and children to receive the services they need for better health outcomes. Frequently based in the communities where they are from, community health workers (CHWs) have direct access to the community and can link with other nutrition-related community-based service providers. They can provide clients with a range of services such as medical care, information, counseling, and referral. However, CHWs are often expected to carry out a wide range of interventions with limited time, resources, and remuneration. They need appropriate academic curricula, training programs, and support systems including systems for monitoring, supporting, and mentoring. Countries like Zambia must take this into consideration as they scale up and expand the services

Information on the services that community health workers provide and the systems that support them in doing their work is often hard to find. To begin to fill this void, the two USAID-funded projects Advancing Partners and Communities (APC) and Strengthening Partnerships , Results, and Innovations in Nutrition Globally (SPRING) collaborated to conduct a desk review of existing policies and documents related to community health systems. Due to the diversity and magnitude of community health programs in a given country, we collected information based on individual country policies/strategies that comprise the key areas of a community health system and not the realities of program implementation. Due to funding and timing, we focused on national public sector programs, and only when possible, captured community-based private sector health programs operating at scale. These are our findings: This is what community

health workers can do in Zambia, according to government policy. See the Data Notes at the end for more on how data were collected and analyzed. We identified only one policy that guides community health service delivery in Zambia. Relevant Government Policies Reviewed National Integrated Strategy for Community Based Health & Social Development Workers and Volunteers in Zambia (2014) Draft Last Update d 2014 Zambia has several distinct cadres* of

community health workers, only one of which provides nutrition Community Health services. 307 in country Assistants (CHA), Zambias primary community health cadre, are formally trained and incorporated into the national health system. *There are other uncoordinated cadres of communitybased volunteers (CBVs), including community-based distributors (CBDs) of family planning. There are an estimated 100,000 CBVs. With a goal of: 1 CHA:3,500 people (rural) 1 CHA:7,000 people (urban) Community health workers in Zambia provide services in multiple health

service delivery areas. Family planning Maternal and child health Services provided by CHAs Services not provided by CHAs Integrated community case management HIV/AIDS Nutrition Malaria Tuberculosis Immunization Water and sanitation

How is training managed for CHW cadres? National training curriculum is available Nutrition is included in the training curriculum Community health workers in Zambia support improved nutrition outcomes throughout the continuum of care. How we present our findings on nutrition services provided by Community Health Assistants. Services, listed in tables, are categorized as nutrition assessment, counseling, or support actions.

Assessment Activity / action to be taken For each stage of life, we indicate if the service is provided by the Community Health Assistants (CHA) of Zambia. Counseling Support Services provided by CHAs The tables presented for each stage of life across the continuum of care include specific nutritionrelated services queried as part of the Community Health Systems Catalog Assessment.

Service not provided by CHA or not clearly specified in policy For adolescents Counseling Provide information/education/counseling (IEC) on iron/ folate for women who are not pregnant and adolescent girls Support Provide/administer iron/folate for women who are not pregnant and adolescent girls For pregnant women Assessment Monitor weight gain during pregnancy Measure mid-upper arm circumference (MUAC) screening for pregnant women Give information on hemoglobin testing for women who are pregnant

Test blood for hemoglobin levels Counseling Provide IEC on nutrition/dietary practices during pregnancy Provide IEC on iron/folate Provide IEC on insecticide-treated net use Support Provide/administer insecticide-treated nets Provide/administer iron/folate For breastfeeding women Assessment Monitor nutritional status of women who are breastfeeding (e.g., using MUAC) Counseling Provide IEC on correct positioning and attachment of the newborn during breastfeeding Provide IEC on managing breastfeeding problems (breast health, perceptions of insufficient breast

milk, etc.) Provide IEC on nutrition/dietary practices during lactation For newborns Assessment Weigh newborns Counseling Provide IEC on skin-to-skin contact between baby and mother/caregiver Provide IEC on breastfeeding within 1 hour of birth For children Assessment Counseling Scales to measure weight of children up to 2 years of age

Provide IEC on Vitamin A for children 6 59 months of age Use length boards to measure length of children up to 2 years of age Provide IEC on general micronutrient supplementation Measure MUAC of children Provide IEC on de-worming medication Screen children for bilateral edema Provide IEC on complementary feeding practices and continued breastfeeding (623 months of age) Support Provide/administer Vitamin A supplementation for children 659

months of age Provide/administer micronutrient supplementation Provide/administer deworming medication Treating moderate acute malnutrition for children under 2 years of age Treat severe acute malnutrition with ready-to-use therapeutic foods (RUTF) or ready-to-use supplementary foods (RUSF) Provide IEC on exclusive breastfeeding (first 6 months of age) Provide IEC on introduction of soft, semisolid foods at 6 months of age Provide IEC on continuing breastfeeding for children less than 6 months of age who have diarrhea Provide IEC on increasing fluids and continuing solid feeding for children over 6 months of age with diarrhea For all stages of life

Counseling Provide IEC on handwashing with soap Provide IEC on community-level total sanitation Provide IEC on household point-of-use water treatment Our key takeaways In Zambia, Community Health Assistants provide 14 of the recommended 38 nutrition services discussed in this assessment. Adolescents Pregnant women Breastfeeding women Newborns Children All stages of life Services provided by CHAs Service not

provided by CHAs or not clearly specified in policy How to use this information You can use the data we have presented here to: Identify which nutrition-related services CHAs can provide, according to policies; Prioritize and/or reassign responsibilities to avoid overburdening CHAs ; Build a stronger foundation of policies, tools, and systems for CHAs to conduct their work; Plan additional support to CHAs ; Design and conduct other in-depth assessments of community nutrition programs; Inform program implementers to strengthen community health interventions.

Data Notes This document includes rich information about community-level nutrition policies and services in Zambia. The data represented here are based on a detailed analysis of survey responses and a review of select policies related to nutrition responsibilities of community health workers. This effort was undertaken as part of the wider Community Health Systems Catalog data collection effort. The data come with their own caveats. Policies do not always specify which particular actions CHWs are allowed or expected to perform, nor do they give any real indication of what actions CHWs actually do perform. Policies can be general, ambiguous, and/or contradictory. For instance, a policy might list "referral for antibiotics" but it doesn't specify which

antibiotics. You can find more details on the Community Health System in Zambia and data on other countries at: www.advancingpartners.org / resources/chsc You can learn more about how to map health workforce activities with the SPRING Nutrition Workforce Mapping Toolkit, available at spring-nutrition.org/publications/tools/nutritionworkforce-mapping-toolkit References Bhutta, Zulfiqar A., Jai K. Das, Arjumand Rizvi, Michelle F. Gaffey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey, Robert E. Black, The Lancet Nutrition Interventions Review Group, the Maternal and Child Nutrition Study Group. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 382 (9890):452-477. doi:10.1016/S0140-6736(13)60996-4. (https://goo.gl/jrMUov)

Global Nutrition Report. 2015 Nutrition Country Profile, Zambia. 2015. (https://goo.gl/JO7P9J) World Bank DataBank. Health Nutrition and Population Statistics. 2016. World Bank Group: Washington, D.C. (https://goo.gl/9XOgGz) Perry, Roger and Rose Zulliger. 2012. How Effective Are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerate Progress in Achieving the Health-related Millennium Development Goals. JHU: Baltimore, MD. (https://goo.gl/ROLw6e) Additional Resources on CHWs Community Health Systems Catalog - An innovative and interactive reference tool on country community health systems intended for ministries of health, program managers, researchers, and donors interested in learning more about the current state of community health systems. (https://goo.gl/N1QKYK) Essential Package of Health Services Country Snapshot Series - A series of country profiles that analyzes the governance dimensions of Essential Packages of Health Services (EPHS), including how government policies contribute to the service coverage, population coverage, and financial coverage of the package (https://goo.gl/2M6FXr) Community Health Worker (CHW) Central - An online community of practice for sharing resources and experiences and discussing questions and ideas on CHW programs and policy. (https://goo.gl/dacnl5) The Community Health Framework - A framework developed for government decision makers to structure dialogues, answer questions, develop recommendations, and foster continuous learning about community health.

(https://goo.gl/VZImbm) Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National H ealth Systems - A systematic review of CHW programs and their impact on health-related Millennium Development Goals (MDGs) as well as eight in-depth country case studies in Sub-Saharan Africa (Ethiopia Mozambique and Uganda), South East Asia (Bangladesh, Pakistan and Thailand) and Latin America (Brazil and Haiti). (https://goo.gl/5G0Vbc) How Effective Are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Pr ograms to Accelerate Progress in Achieving the Health-related Millennium Development Goals - An update and supplement to the previous paper on the effectiveness of CHWs in providing a range of health services and improving health and nutrition outcomes. (https://goo.gl/jKx2Zg) Additional Resources from Zambia Zambia: Nutrition Profile USAID is prioritizing our nutrition efforts on focus countries where there is high burden of stunting and the Rome Principles, including country ownership and coordination, can be realized in practice. (https://goo.gl/3nNFep) Evidence-Based Community Healthcare in Zambia - An evaluation led by researchers from Harvard Business School and the London School of Economics found that shifting the emphasis from social incentives to career incentives when recruiting CHWs in Zambia, attracted workers who were more qualified and performed better on the job. (https://goo.gl/b2RzxP) Access to healthcare through community health workers in East and Southern Africa This report

examines current community-level provision of health services through CHWs. Through this examination, the report will provide clarification of their current and potential contributions to national healthcare systems. (https://goo.gl/RdlPOS) Innovation in health service delivery: integrating community health assistants into the health system at district level in Zambia This paper explores factors that shaped the acceptability and adoption of CHAs into health systems at district level in Zambia during the pilot phase. It outlines both successes and challenges that were faced through this process, and the perceived compatibility and advantage of CHAs over existing community-based health workers during the implementation phase. (https://goo.gl/AFnpGE) Developing the national community health assistant strategy in Zambia: a policy analysis This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognizing the fact that actors power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform. (https://goo.gl/SvTZFy) Learn more at: www.spring-nutrition.org

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