Cover Page

Table of ContentsIntroduction ............................................................................................................................................3

Background / Context .............................................................................................................................4

Situation Analysis ................................................................................................................................4

Evidence ..............................................................................................................................................4

Summary of previous policy................................................................................................................4

Why we are revising the previous policy ............................................................................................4

Description of policy revision process ................................................................................................4

Guiding Principles ...............................................................................................................................4

Goals and Objectives...............................................................................................................................4

Key stakeholders .....................................................................................................................................5

Ministry of Health and Sanitation.......................................................................................................5

National CHW Hub, Directorate of Primary Health Care ................................................................5

District Health Management Teams ...............................................................................................5

Relevant MOHS Programs and Directorates...................................................................................6

Development Partners ........................................................................................................................6

Implementing Partners .......................................................................................................................6

Definition of a CHW ................................................................................................................................6

Scope of Work.........................................................................................................................................7

Selection Criteria.....................................................................................................................................9

CHWs...................................................................................................................................................9

Peer Supervisors ...............................................................................................................................11

Coverage ...............................................................................................................................................13

Supervision............................................................................................................................................15

M&E and Reporting...............................................................................................................................19

Incentives and Motivation ....................................................................................................................22

Community Engagement ......................................................................................................................23

Program Management and Coordination.............................................................................................24

Support to CHWs / Inputs Required .....................................................................................................26

Training .............................................................................................................................................26

Drugs, Health Commodities, Supply Chain, Logistics........................................................................28

Urban CHWs..........................................................................................................................................30

Overview ...........................................................................................................................................30

Scope of Work...................................................................................................................................31

Incentives and Motivation ................................................................................................................31

Coverage ...........................................................................................................................................32

IntroductionSierra Leone’s National CHW Program has been in existence since 2012, when the Ministry of Healthand Sanitation, supported by partners, created a national CHW policy focused on providing a basicand polyvalent package of services at the community-level. This national program was built ondecades of efforts to bring essential services to communities across the country, through a variety ofvertical community-based programs, such as Community Drug Distributors through the NeglectedTropical Diseases (NTDs) Program and Community Based Providers through the National MalariaControl Program. Many non-governmental organizations additionally promoted community-basedcare through community-based workers and volunteers. Together, these programs havedemonstrated the importance of providing care at the community level. The 2016 CommunityHealth Worker Policy continues to build on the 2012 effort to strengthen and harmonize differentcommunity-based programs to provide comprehensive primary health care at the community levelby providing further guidance for: appropriate scope of work for CHWs; coordination andimplementation of the national CHW program; supervision for CHWs; remuneration for CHWs; andtraining for the cadre. The National CHW Program aims to achieve national scale so that all hard-to-reach communities receive a basic but comprehensive package of services within their community.

The 2016 Community Health Worker Policy should be read as a minimum package of services to beprovided by CHWs, and a minimum package of services required to support those CHWs. All Ministryprograms and directorates, partners, and donors working to implement and support the NationalCHW Program must be working towards providing the minimum standards outlined in this policy.

However, the National CHW Program recognizes the importance of continuous learning and buildingon the program to make it stronger. It is in this spirit that the 2016 National Community HealthWorker Policy should be read as a floor, not a ceiling. The Ministry welcomes innovations anditerative learning that will foster the strong CHW program possible.

Sierra Leone’s national CHW program, focuses on hard-to-reach areas, defined as communities thatare more than 5 km or one hour’s walk from a health facility. DHMTs can also identify areas that arenot considered “hard to reach,” as per this definition, but who require additional health services,such as those with very poor health indicators where CHWs may provide an additional service.

Background / Context

Situation Analysis

Evidence

Summary of previous policy

Why we are revising the previous policy

Description of policy revision process

Guiding PrinciplesThe National CHW Program, overseen by the Ministry of Health and Sanitation, is guided by a set ofkey principles. These are:

1. To save lives, particularly those of pregnant women, lactating mothers, newborns, andchildren under five

2. To deliver an evidence-based and high-quality program that delivers high-quality services3. To be led by the Government of Sierra Leone, particularly the Ministry of Health and

Sanitation at all levels (national, district, primary care, community)4. To foster community engagement and community ownership in order to ensure that the

National CHW Program ultimately meets the needs of and is accountable to thecommunities it serves

5. To foster an environment of partnership and coordination.6. To ensure complementarity, not duplication, of services and efforts at all levels: community,

district, and national. This includes ensuring joint and proper planning of the program andcomplimentary programs at all levels.

7. To ensure transparency and accountability at all levels.8. To ensure that community-based services are equitably offered and accessed across Sierra

Leone.

Goals and ObjectivesThey overall objectives of Sierra Leone’s National CHW Program are to contribute to significantreductions in both maternal and child morbidity and mortality. This will be achieved throughbettering healthy behaviours and care-seeking behaviours by community members; increased use ofhealth facilities by community members, particularly pregnant and lactating mothers and childrenunder five; and increased access to basic preventative and curative treatments at the community-level. This will be achieved through the following sub-objectives:

Outcomes:

Increase number and percentage of pregnant women accessing comprehensive ANC andPNC services.

Increase number and percentage of women giving birth at a facility.

Increased number and percentage of children under five receiving full recommendedimmunization package

Increased positive healthy behaviours by community members, such as increased use ofITNs, reduced open defecation, and increased handwashing

Increased access to basic reproductive health services at the community level Increased reporting of births and deaths at a community level Institution and implementation of a strong community-level IDSR system, which includes

weekly reporting on key events from the community level

Outputs:

Increased case finding of and treatment for malaria in hard-to-reach populations. Early identification of and early treatment for malaria in the community before

complications occur. Early referral of potential complications to the health facility. Increased case finding of and treatment for diarrhoea and pneumonia in children under five. Increase identification of pregnant women in communities within the first trimester. Increased case finding of and referral for danger signs in pregnant women. Increased case finding of and referral for danger signs in newborns. Increased case finding and referral of severe acute malnutrition in children under five.

Key stakeholders

Ministry of Health and SanitationNational CHW Hub, Directorate of Primary Health CareThe Ministry of Health and Sanitation is the lead party in the National CHW Program, responsible forproviding policy, strategy, financing, and implementation guidelines and guidance.

The National CHW Hub is the primary body within the MOHS responsible for the program. The Hubsits within the Directorate of Primary Health Care, MOHS. At the time of writing, the Hub consistedof a finance officer, M & E component, four regional coordinators, and one national coordinator,who are together overseen by the Director of Primary Health Care. The regional coordinators areresponsible for providing support to the CHW program at district level through quarterly site visits.The national coordinator is responsible for working with the Government of Sierra Leone andpartners to ensure coordination, harmonization, oversee implementation, and ensure appropriatepolicy guidance. The Director oversees all efforts and provides leadership support. Together, theNational CHW Hub is responsible for overseeing fundraising, implementation, and policy, includingfacilitating the CHW Steering Committee and Technical Working Group (see “Program Managementand Coordination”).District Health Management TeamsDHMTs are responsible for overseeing implementation of the National CHW Program at the districtlevel. This may include implementing the program through the DHMT or supporting ImplementingPartners to do so. This also includes overseeing CHW data at the district level and ensuring regularsupervision of all CHWs in the district. The DHMT M & E Focal, CHW Focal, and Surveillance Focal areespecially essential to ensuring operationalization of the 2016 National CHW Policy.

Relevant MOHS Programs and DirectoratesThere are many MOHS programs and directorates who have for many decades worked directly withor supported different types of Community Health Workers and continue to work with, support, andhave a stake in the National CHW Program. These include, but are not limited to, the NationalMalaria Control Program, National TB/Leprosy Control Program, National AIDS Control Program,Nutrition Directorate, Directorate of Reproductive and Child Health, Directorate of DiseasePrevention and Control, and Environmental Health and Sanitation Directorate, as well as supportingdirectorates such as the Directorate of Planning, Policy and Information and Directorate ofFinancing. Together, these MOHS programs work with and support the National CHW Hub, especiallyon issues of harmonization and integration, policy guidance, and M & E. As such, they are expectedto regularly report to and work with the CHW Technical Working Group and CHW SteeringCommittee. The National CHW Hub is responsible for reporting its activities to affected directorateson at least a quarterly basis.

Development PartnersDevelopment partners, particularly UNICEF, have long been supporters of both the polyvalentNational CHW Program, first implemented in 2012, and vertical CHW programs that have existed inSierra Leone for decades. UNICEF continues to be a key supporter of the National CHW Program,primarily through providing technical support, fundraising support, and guiding policy andimplementation. UNICEF works closely with the National CHW Hub in this regard.

Implementing PartnersAt the time of writing, the National CHW Program is implemented by both local and internationalNGOs in many districts. Implementing Partners are responsible for implementing the program asoutlined by the National CHW Hub in this policy, working closely with the DHMT to do so andproviding extra support as needed.

Definition of a CHWA Community Health Worker (CHW) is a community-based person who is recognized by the MOHS,meets the selection criteria outlined in this policy document, is trained in the national trainingprogram, implements the services in the Scope of Work outlined in this policy document, and issupported in their work as outlined in this document.

All programs implementing the national program must be working towards implementing the fullpackage of services. The MOHS recognizes that implementing the full national program in a newgeographic area or by a new partner may require a phased-in approach, but does require that allnational programs be working towards implementing the full package. A program that isimplementing one component of the national program (ex. MNH promotion) without any intentionof phasing in the other components (ex. iCCM) is not implementing the national program, and maybe duplicating or competing.

Community-based programs may work outside the official national program, if they areimplementing services that are not included in the national program SOW (ex. Community DOTS,injectable contraceptives). However, this program must be agreed upon and overseen by the DHMT

responsible for administering health services in that specific locality, and communicated to the CHWHub at the Ministry of Health and Sanitation.

DHMTs must provide certificates and ID cards for CHWs that fall within the National Program todifferentiate them from those who do not.

Scope of WorkThis document outlines the official Scope of Work (SOW) for CHWs serving under the National CHWProgram. Considering evidence of feasibility, effectiveness, and impact both internationally andwithin Sierra Leone, the SOW has been designed to prioritize high-impact, cost-effectiveinterventions that achieve the objective of reducing maternal and child morbidity and mortality andimproving maternal and child health outcomes. It additionally addresses selected prominentinfectious disease concerns. The SOW has been designed to align with the continuum of care in theSierra Leone health system and complement the roles of other health workers (particularly MCHAides), while equally being ‘demand-driven’ to meet the needs and the expressed desires forcommunity-level services of the communities the program serves.

The SOW outlined in this document is a minimum standard, akin to the Basic Package of EssentialHealth Services designed for the Sierra Leone health system. Additional services may be added to theCHW SOW under a particular program, in a particular geographic area, by a DHMT or by animplementing partner. This can be based on a localized disease burden, or as a pilot study to test thefeasibility, effectiveness, and/or impact of a proposed intervention. However, all justifications foradditions to the SOW must be discussed with and agreed by the communities affected, CHW(s)1 whowill implement the service(s), the National CHW Program, the DHMT in the district where theadditional service(s) will be implemented, and relevant program(s) within the MOHS (for example, apilot study of CHWs providing injectable contraceptives would have to be approved by theDirectorate of Reproductive and Child Health in addition to the National CHW Program (Directorateof Primary Health Care) and the DHMT of the district in which the pilot will be conducted).

Partners and DHMTs considering adding services to the SOW must also consider the implications ofan activities time, resource, and competency implications SOW outlined in this document. CHWsimplementing additional services must be well supported to do so and be compensated fairly for theirtime and efforts.

The National CHW Program will incorporate RMNCH, iCCM, and community IDSR (Community-BasedSurveillance, or CBS). There is also a community HIV and TB program which is associated with theNational CHW Program, but is implemented separately (vertical integration). Where a TB and/or HIVCHW fulfils the qualifications to implement other components of the official national SOW, theseservices may be combined with one person (i.e. a CHW providing MNH, iCCM, CBS and HIV/TB),considering the time burden and feasibility involved while also ensuring that the individual isadequately supported and compensated. This can be determined on a case-by-case basis atimplementation level.

1 Before deciding to add on services, it is important to discuss with CHWs about the need for the service withinthe community, whether there is adequate demand and acceptability for the service within their communities,whether the CHWs feel confident in their capacities to implement the service, and the inputs they wouldrequire do to so effectively.

Throughout their work, CHWs are expected to practice infection prevention and control (IPC)measures for their own safety and for the protection of their communities. IPC is a cross-cuttingcomponent of the implementation of all elements of the SOW. CHWs will be trained in communityIPC protocols and will be provided with the necessary supplies.

The harmonized official Scope of Work of the National CHW Program is as follows:

Reproductive, Maternal, Neonatal, and Child Health:

Community sensitization for behavior changeo Preventive and promotive behaviors for maternal, neonatal, child health, including

WASH, IYCF, FP, immunization ANC and PNC Home visits to promote uptake of facility based care during pregnancy,

delivery and postnatal periodo Identify danger signs in pregnancy and postnatal period (mother and newborn)o Provide in-community ANC and PNC visitso Promotion of Essential Newborn Care (education through ANC, very basic

preparedness for births that take place in the community despite encouragement offacility births)

o Provide IPT to pregnant women iCCM:

o Identification and treatment of pneumonia, diarrhea, and malaria in under-5’s,referral of complications

o Identification and treatment of malaria in older children and adults (entirepopulation)

o Follow-up care for patients who are on treatment and who have finished treatment Screen under-5’s for MAM and SAM (MUAC) and refer to health facility

o Provide in-community support for adherence to SFP and CMAM treatmento Assessing patients for in-home feeding practiceso Provide in-community follow-up support after SFP and CMAM discharge

Report birth, maternal and under five deaths in the community Family Planning: Condom distribution and refill birth control pills Social mobilization for specialized campaigns (examples: Welbodi Weeks (MCH Week),

National Immunization Days (NIDs))

Disease Prevention and Control:

Community-IDSR (CBS): Surveillance and reporting of any events related to the following diseases /conditions:

Acute Flaccid Paralysis (Polio) Acute Watery Diarrhoea Clustered deaths Guinea Worm Maternal Death Measles Neonatal Tetanus Neonatal Death Suspected Ebola Yellow Fever

Sensitization of communities about

TB risk factors, signs and symptoms, referral for testing

HIV risk factors, signs and symptoms, referral for testing

The official scope of work for the associated community TB and HIV programs is as follows:

TB:

Treatment adherence support for TB patients Defaulter tracing Contact tracing

HIV:

Treatment adherence support for HIV+ patients Defaulter tracing Psychosocial support

Selection Criteria

CHWsSelection Process

New CHWs must be selected in a fair and transparent manner that gives equal opportunity to allqualified candidates in a community. This policy provides guidance for standardized procedures forselecting new CHWs that are intended to ensure both equal opportunity and selection of the bestcandidate to do the job.

Selection of CHWs is a joint / participatory effort between the community structure (VDC, FMC, orother local leadership as appropriate per community) and the in-charge of the PHU to which theCHW will be attached. In order to ensure community ownership, local political structures (such aschiefs, councillors, etc.) can be involved in the selection process, but should not be in charge of theprocess, so as to dissuade undue influence. In any case where the PHU staff and communitydisagree, the Chiefdom Supervisor will be called upon to mediate and finalize the selection. IPs andChiefdom Supervisors should not select CHWs independently of community structures and PHUstaff, but they should work together to play a facilitating role to ensure the selection process iscarried out appropriately and in a timely manner.

DHMTs are not directly involved in individual CHW selection. DHMTs receive CHW listings from thePHU staff, register CHWs in the district database, and provide certificate and ID card to CHWs whohave been selected, after the CHWs successfully complete the training and begin their service.

Women should be encouraged to serve as CHWs. If there are a male and a female candidate withsimilar skills and motivation, preference should be given to the female candidate

Replacement of CHWs

All CHWs will undergo a standardized pre-service training package, as well as annually receive astandardized refresher training annually. For all trainings, all CHWs will be required to do a pre- andpost-test to help determine their competencies and ability to learn. CHWs who repeatedly orconsecutively (at least twice) fail training post-tests will be eligible for replacement. Selection willagain be done in the aforementioned manner.

The National CHW Program will conduct an annual performance evaluation of CHWs. Based on thisevaluation, if a CHW is determined to not be fulfilling their roles and responsibilities as laid out in the

TOR, the program will identify extra support that CHWs (either individually or as a larger group) needto receive in order to improve how they do their jobs. If a CHW does not improve, then the programmay decide to remove that CHW from the program and replace them (i.e. ‘firing’ of CHWs)

CHWs may also be replaced for the following:

Failing to submit reports for three (3) months consecutively Failing to attend the monthly PHU meeting for three (3) month consecutively Selling or accepting fees for services, drugs, or supplies that are intended to be provided for

free Providing services that are not included in the agreed SOW Repeated complaints received from the community and/or Peer Supervisor about

inappropriate conduct or disrespectful interactions with clients Frequent absence from their community Absence from their community, without notice, for more than one month

Community Structures and IPs must refer any complaints they receive directly to the PHU andChiefdom Supervisor. PHU staff, in collaboration with Chiefdom Supervisor and the IP, areresponsible for investigating any of the above. PHU staff and the Chiefdom Supervisor must takeaction as necessary.

When a CHW leaves their role, the Chiefdom Supervisor is responsible for ensuring that thecommunity receives services in the interim until the CHW can be replaced (for example, by assigninga CHW from a neighbouring community to expand their coverage area, by asking the Peer Supervisorto fill in, bringing a retired CHW back into temporary service, asking the PHU staff to intensifyoutreach services, or other method as determined to be appropriate in the local context).

The DHMT is responsible for determining when new CHWs will enter the program and organizingpre-service trainings for new CHWs. In the interim, new CHWs will join the next available refreshertraining, if one is already scheduled, and will receive intensified on-the-job in-service training fromthe chiefdom supervisor, and then will join the next pre-service training when it is scheduled by theDHMT. PHU staff and Peer Supervisors must also prioritize for intensified supervision new CHWswho have only gone through refresher training and are awaiting pre-service training.

Terms of Reference

Any person serving as a Community Health Worker under the National CHW Program is expected tofulfil the following roles and responsibilities.

Able and willing to fulfil the Scope of Work outlined in the National CHW Policy Provide the SOW to their designated catchment area Must be available to meet community health needs Provide services in a high quality, respectful manner Attend monthly meetings at the PHU Report to the Peer Supervisor as required (per this policy) Submit reports on time (monthly reports and more frequent for notifiable diseases) Participate in local community structures (FMCs, VDCs, etc.)

Selection Criteria (Qualifications)

CHWs will be selected based on the following minimum standard criteria. Any person in acommunity fulfilling these qualifications may be considered by the community and the MOHS to beselected as a CHW under the national program.

Should be exemplary, honest, trustworthy and respected She/he should be willing, able, and motivated to serve their community. Must be a resident of the community and willing to work with the community. Should be available to perform specified CHW tasks, as outlined in the Scope of Work Should be interested in community health and development matters Ideally has been involved in community projects in the past Should be a good mobiliser and communicator May already be a Community Health Volunteer, TBA, condom distributor, or youths trained

in life skills Literacy is not required, but it is preferable when possible Permanent member of the community aged 18 years and above

Peer SupervisorsSelection Process

New Peer Supervisors must be selected in a fair and transparent manner that gives equalopportunity to all qualified candidates. This policy provides guidance for standardized procedures forselecting new Peer Supervisors that are intended to ensure both equal opportunity and selection ofthe best candidate to do the job.

The PHU staff and local structure will jointly nominate CHWs they have identified as high-performingand refer them to the Chiefdom Supervisor. This recommendation must be documented. TheChiefdom Supervisor is responsible for validation and approval of the selected candidate, incollaboration with the District CHW Focal. The Chiefdom Supervisor communicates this decision tothe DHMT.

The DHMT is responsible for registering selected Peer Supervisors and providing them with acertificate and ID card. Women should be encouraged to apply. If there are a male and a femalecandidate with similar skills and motivation, preference should be given to the female candidate

Peer supervisor selection criteria and process will be subject to review based on developments inMOHS HRH strategy.

Removal and Replacement of Peer Supervisors

Peer supervisors who are not performing their roles adequately can be removed. The National CHWProgram will conduct an annual performance evaluation of Peer Supervisors. Based on thisevaluation, if a Peer Supervisor is determined to not be fulfilling their roles and responsibilities aslaid out in the TOR, the program will identify extra support that Peer Supervisors (either individuallyor as a larger group) need to receive in order to improve how they do their jobs. If a Peer Supervisordoes not improve, then the program may decide to remove that Peer Supervisor from the programand replace them (i.e. ‘firing’ of Peer Supervisors).

Peer Supervisors may also be replaced for the following:

Failing to report to the PHU as required

Failing to attend the monthly PHU meeting for two (2) month consecutively without notice Selling or accepting fees for services, drugs, or supplies that are intended to be provided for

free Providing services that are not included in the agreed SOW Repeated complaints received from the community and/or CHW and/or PHU about

inappropriate conduct or disrespectful interactions with clients Frequent absence from their role Absence from their role, without notice, for more than one month

Community Structures, PHU staff, and IPs must refer any complaints they receive directly to theChiefdom Supervisor and District CHW Focal Point. Chiefdom Supervisors, in collaboration withDistrict CHW Focal and the IP, are responsible for investigating any of the above. The ChiefdomSupervisor and CHW focal must take action as necessary.

The DHMT is responsible for determining when new Peer Supervisor trainings are needed. In theinterim, new Peer Supervisors will join the next available Supervision refresher training, if one isalready scheduled, and will receive intensified on-the-job in-service training from the chiefdomsupervisor, and then will join the next pre-service training when it is scheduled by the DHMT. PHUstaff and Chiefdom Supervisors must also prioritize for intensified supervision new Peer Supervisorswho have only gone through refresher training and are awaiting pre-service training.

Terms of Reference

Peer Supervisors within the National CHW Program are expected to fulfil the following roles andresponsibilities.

Supervise all CHWs in their catchment area at least twice per month Attend monthly meetings at the PHU Mobilize CHWs to attend monthly meetings at the PHU Report to the PHU, including but not limited to:

o Compile CHW reports and submit to PHU in-chargeo Inform PHU of findings from in-community supervisionso Other responsibilities as outline in the M&E and supervision sections of this policy

Ensure CHWs are providing their SOW in their community Provide on-the-job mentoring and support to ensure the quality of the services CHWs are

providing to their community Participate in community structures (FMC, VDC, etc.) Ensure strong working relationship between CHWs and the PHU Identify and report stock-outs at community level to the PHU

Selection Criteria (Qualifications)

Peer Supervisors will be selected based on the following minimum standard criteria. Any personfulfilling these qualifications may be considered by the community and the MOHS to be selected as aPeer Supervisor under the national program.

Must be a CHW who has served for at least one year and has a demonstrated record of highquality performance

Must be a permanent resident of a community within the PHU catchment area, or aprevious resident who is willing to return to live in the catchment area for the purpose ofserving this role, aged 18 years and above

Must be literate (in English) Basic education through completion of JSS 3, or equivalent Should be a good mobiliser and communicator Willing and able to provide the services Able to compile data for both general CHW program and CBS component

CoverageThe coverage recommendation in the 2012 National CHW Policy was to have 1 CHW for every 100 to500 people (or 20 to 100 households). However, little context was provided for why the coveragerange was so expansive, and there was little guidance for IPs to follow to determine the appropriatecoverage ratio for the localities they were working in, in either the policy or the accompanyingstrategy document.

According to the geo-mapping conducted in 2015, CHWs in 12 districts (excluding Western Area) arecovering an average of 436 people encompassing an average of 98 children under-five and 94households. There is significant variation of coverage by district, with the lowest district averagearound 1 CHW per 300 people (Port Loko, Moyamba, Kambia, and Bombali all are in this range), andthe highest at one CHW per up to 700 people (Pujehun and Koinadugu are both in this range). Theratio also varies greatly by implementing partner.

Based on implementation experience between 2012 and 2015, implementers have suggested thatthe proposed range of 100-500 population (20-100 households) does provide a feasible coveragearea for CHWs, but that more guidance regarding where in this range the coverage ratio should fallwould be particularly helpful. Therefore, the recommendation remains that 1 CHW should coverbetween 100-500 individuals, but that the specific circumstances of each community will impact theexact ratio, and that some communities may require a ratio that falls outside of the nationalrecommendation.

It is generally understood that there will be one CHW per one hard-to-reach community. However,depending on the specifics of a community, one CHW may be asked to cover more than onecommunity, for example if there is a cluster of villages that have a low population and are in closeproximity to one another. Equally, there may be more than one CHW per community, such as in thecase of a large community or a community with a disproportionate disease burden.

Coverage decisions in the National CHW Program are decentralized to the district level, and shouldbe a joint effort between the DHMT, led by the DMO and District CHW Focal Point, the DistrictCouncil, and IPs to determine the appropriate number and distribution of CHWs in each locality.The National CHW Hub will also assist the district in conducting the analysis and making thecoverage decisions for that district.

The following section outlines the considerations that DHMTs and IPs should prioritize in makingcoverage decisions at the district level.

1. Population Density

CHWs will be provided with a fixed amount of transportation support per month (as described in theincentives and motivation section of this policy), and are not expected to provide CHW services at afull-time level of effort or in place of other livelihood activities. For these reasons, the distance CHWsmust travel must not present a significant time or financial burden. In areas with higher populationdensity, CHWs may be expected to cover a higher number of people / households, because theburden in terms of distance and time between clients will be less. In areas with lower populationdensity, the program must account for transit time and reduce the coverage accordingly.

2. Terrain

Similarly to distance, terrain will greatly affect the amount of time and effort CHWs spend to reachthe populations they serve. In flat areas that are easily traversed, CHWs can cover a higher numberof people. In mountainous and riverine areas, CHWs may face higher time and cost burdens, andthus may be expected to serve fewer people.

3. Facility and health workforce density and functionality

The National CHW Program primarily targets hard-to-reach areas, which are classified as anycommunity further than a 5 km radius from a PHU, and/or more than one hour’s walk from the PHU.Any decision to place a CHW in a community within 5km or one hour’s walk of a PHU must bestrongly justified by disease burden, low functionality of the facility, under-staffing, or other criteria,and must be determined by the DHMT (DMO and CHW Focal Point), in collaboration with the IP (ifapplicable in that district), and approved by the National CHW Hub.

4. Disease burden

The program focuses on remote and hard-to-reach areas in part on the assumption that populationswith lower access to health facilities have a higher disease burden, and that hard-to-reachcommunities are less likely to be able to receive the basic preventive and curative services theyneed, especially for the country’s biggest killers, including malaria, pneumonia, diarrhoea, andmaternal mortality. If there are localities within the district that have particularly high diseaseburden (ex. cultural variances in child feeding practices leading to higher rates of malnutrition,mining areas leading to higher incidence of malaria, etc.) then CHWs serving in those areas canexpect to have a higher workload when serving the same number of people as a CHWs in a lowerdisease prevalence locality. In this case, districts may want to give CHWs in higher burden areas alower coverage ratio so they can focus their efforts on impacting that targeted group, while it maybe more feasible for CHWs in lower disease burden areas to reach a larger number of people orhouseholds with lower intensity services.

The National CHW Program now supports vertical community-based HIV and TB services, which willbe delivered by people living with or affected by the respective disease through a peer-to-peermodel. Providing HIV and TB services at a community level is generally considered to be time-intensive, as it requires significant and regular linkage to the PHU and significant adherence andpsychosocial support to people affected by both diseases. Districts should work with the HIV and TBprograms, with significant support from the National CHW Hub, to identify communities that haveclustered higher prevalence rates and would benefit most from these services, to understand the

time required to provide these services to the number of people requiring them, and to understandthe distance, terrain, and other transport implications involved. Based on this, districts candetermine their coverage needs and the number of CHWs they need to recruit into these specificprograms.

5. Scope of Work and time burden of tasks

The more services a CHW is expected to perform, and the more time their tasks take, the fewerpeople they can be expected to reach with those services, especially considering the financial andnon-financial support provided. Particularly in localities where the DHMT together with animplementing partner has added an additional service based on community need, or is conductingresearch on an additional service, it will be important to consider scaling back the coverage of theCHWs being asked to expand their scope of work, and/or significantly increase the support to theCHWs providing additional service(s). These determinations should be proposed by the DHMT,jointly with the IP, and approved by the national CHW Hub.

6. Motivational package, incentives, and job support

The more a CHW is paid, the more work they can be expected to perform, including building inadditional time and resources to support transportation to further areas. CHWs who are paid a livingwage can be expected to dedicate the equivalent of full-time level of effort to their CHW work, whileCHWs who are only paid the minimum recommended standard in this policy can be expected tospend more time outside of their CHW work engaging in supplementary livelihood activities tocomplement their income (farming, trading, mining, etc.).

SupervisionSupervision is a key backbone of any successful CHW program: CHWS need to receive regular andsupportive supervision in order to ensure high-quality service provision, continuity of provisions tothe cadre, and timely and quality reporting. Supervision is particularly needed in order to providefeedback to CHWs themselves about their work, and to act as a link between CHWs and the PHUs,implementing partners, and DHMTs to which they are attached. Good supervision will help to ensurethat the CHW program is performing adequately by overseeing CHWs work and ensuring CHWs havethe inputs they need to do their job effectively.

The 2016 National CHW Policy places a much greater emphasis on strong supervision, as comparedto the 2012 National CHW Policy. While historically supervision has primarily focused on collectingdata from CHWs, the reformed policy focuses on a more holistic and supportive approach tosupervision, in which data collection is only one component. Supervision ultimately must focus moreon ensuring a supportive working environment for CHWs so that they can perform their job well,which will ultimately lead to strengthen the program and ensure high-quality provision of services.

The National CHW Program sees the following elements as key to effective supervision:

Ensuring the full package of services (outlined in the Scope of Work) is being provided byCHWs to the community.

Ensuring additional services and activities are not being provided by CHWs unless agreedupon by the Ministry of Health and Sanitation.

Considering and supporting technical capacity of CHWs. This includes providing spot-checksof CHWs and regular performance evaluations, and providing refresher trainings and on-the-job training to CHWs, particularly to those who are low-performing, while replacing thosewho are continually under-performing as needed.

Providing support to CHWs, including through regular communication on CHWs’performance and offering positive feedback when appropriate.

Ensuring accurate and timely reporting. Ensuring effective linkage between CHWs and their respective PHUs, and CHWs and their

respective communities. This includes dispute resolution as needed. Ensuring that CHWs have adequate supplies to perform the full package of services. Providing ongoing mentorship to CHWs.

Each PHU in-charge is ultimately responsible for ensuring high-quality and frequent supervision ofCHWs in their catchment area. This includes helping to train (both pre-service and refresher) CHWs,overseeing the work of Peer Supervisors, facilitating monthly CHW meetings at the PHU, conductingspot checks when possible, compiling CHW reporting forms and ensuring they are fed to the DHMT,assisting with annual performance reviews, and providing clinical mentorship to CHWs as needed.However, the Ministry of Health and Sanitation recognizes that Sierra Leone has a limited healthwork force. At many clinics, there is only one staff. It is not feasible to ask clinic staff to provide theregular, in-community supervision that CHWs need to perform their job and ensure a high-qualityprogram, without over-burdening PHU in-charges and leaving PHUs unattended for long periods oftime. Therefore, peer supervisors are considered as an extension of the PHU in order to provideregular supervision to CHWs at the community level.

Peer Supervisors are well-trained community-members, with a higher education background andskill set as compared to CHWs, and who offer supportive, in-community supervision. These PeerSupervisors will be responsible for ensuring the day-to-day functioning of the program, quality ofthat program, additional inputs needed for the program to function (such as additional training,additional supplies, etc.), and will act as a link between the CHWs and the formal health service, aswell as between CHWs and their respective communities. Peer Supervisors will do this through bi-weekly in-community supervision visits, once-weekly supervision phone calls, and by organizing andhelping to lead once-monthly CHW meetings at their respective PHU. They are also responsible forassisting with annual performance reviews of CHWs. Because of the importance of robustsupervision, Peer Supervisors exist solely as supervisors and do not perform CHW roles (such asservice provision through iCCM, etc.). This represents a significant shift from the 2012 National CHWProgram, in which Peer Supervisors did additionally act as CHWs.

It is very important to note that Peer Supervisors should be seen as a mechanism to supportsupervision from the PHU, not as a replacement for PHU supervision. They are ultimately responsiblefor providing the link between CHWs and PHU staff, including by supporting PHU staff as needed.

Supervision from PHU in-charges and peer supervisors is additionally supported by ChiefdomSupervisors, implementing partner staff, DHMT CHW Focal Points, and regional coordinators fromthe National CHW Hub. Program-specific supervision from the National CHW Hub will be conducted

on a quarterly basis. The CHW program will also be included in the national supportive supervisionprogram.

Roles and responsibilities2:

PHU in-charges:

Responsible for ensuring regular, in-community supportive supervision of CHWs. Thisincludes supervising Peer Supervisors.

Provide monthly in-community supervision of a select number of Peer Supervisors andCHWs. Additionally provide targeted ad-hoc supervision and on-the-job training of CHWsbased on feedback from Peer Supervisors on low-performing CHWs who need intensifiedsupervision, especially on clinical aspects of the program (such as administering drugsthrough iCCM). Supervision may additionally be needed if CHWs’ Scope of Work increases.

Lead monthly CHW meetings at the PHU. Ensure regular and adequate supply of provisions for CHWs (such as drugs, incentives, etc.) Provide positive feedback to CHWs, as needed Provide clinical mentorship to CHWs Compile CHW data and submit to DHMT

Peer supervisors:

Based at the PHU, but are mobile and provide regular supportive supervision to CHWs withinthe community.

Supervise each CHW within their community twice per month. This includes identifying low-performing CHWs through spot checks and providing on-the-job training and identifying theneed for extra support as appropriate. It also includes providing positive feedback to CHWs,as needed.

Provide feedback to the PHU and implementing partner on CHW program, including but notlimited to consistently low-performing CHWs.

Provide weekly supportive phone calls to CHWs. Assist the PHU in-charge in organizing monthly CHW meetings at the PHU; assist in

facilitating these meetings. Ensure timely and accurate reporting. Particular attention will be placed on reporting for

Community-Based Surveillance. Assist with annual performance reviews of CHWs. Ensure regular and adequate supply of provisions for CHWs (such as drugs, incentives, etc.) Ensure a strong working relationship between CHWs and the PHU

Chiefdom/Zonal supervisors:

Oversee PHU staff interactions with all CHWS in their chiefdom. This includes ensuring thatCHWs receive regular, adequate, and supportive supervision. This primarily requiresensuring that PHU staff are ensuring supervision of CHWs.

Chiefdom/Zonal Supervisors are also responsible for providing monthly supervision of aselect group of CHWs themselves. This will primarily be done through spot checks of CHWs,to ensure that they are working, that they are providing high-quality services, to providefeedback on the overall program and suggest changes as needed, and to answer questionsand troubleshoot issues as they arise.

2 Adequate supplies for supervisors, such as supervision checklists and other tools, will be provided by theNational CHW Program.

• Chiefdom/Zonal Supervisors must also ensure that CHWs are included in routine integratedsupervision

District CHW Focal Points:

Conduct joint supervision, together with IP(s), on a monthly basis. This supervision shouldtake place at the PHU and at the community-level. A primary focus of these visits will be toensure that regular, adequate and supportive supervision of CHWs is taking place, that theprogram (including CHWs) are well supported, and that CHWs are providing high-qualityservices.

Within a year, all PHUs within a district must be visited at least once.

Implementing Partners:

Support supervision at all levels and by all actors. Specifically, implementing partners shouldhelp to ensure that CHWs receive regular supervision in the field and assist all supervisors inperforming their job well, including ensuring that this supervision is supportive and of high-quality. This could include hiring CHW specific supervisors to assist at a district-wide level.

o If IPs feel that supervision is inadequate, solutions—such as more supervision,different supervision, or innovative interventions—need to be discussed with andagreed upon by the DHMT. Program-specific supervision of CHWs that takes placeoutside of the national CHW program must be communicated to the District CHWFocal Point and National CHW Program, through the respective regional coordinator.

Join and assist supervision conducted by Chiefdom/Zonal Supervisors, District CHW FocalPoints, and Regional Coordinators. This supervision should take place at the PHU and at thecommunity-level. Within a year, all PHUs within a district must be visited at least once.

Assist with identifying and providing refresher trainings and on-the-job training to low-performing CHWs.

Regional Coordinators, National CHW Program:

• Assist District CHW Focal Points in conducting quarterly supervisory visits. This will includeensuring that the program is implemented as agreed upon and is of high quality.Each district should receive quarterly supervision from their respective RegionalCoordinator. During these visits, coordinators will meet with the DHMT (CHW focal point)and IP(s), as well as a selection of PHU in-charges and CHWs.

M&E and ReportingOverview:

Data for Decision Making and Operational Research:

The National CHW Program is committed to regularly and robustly monitoring and evaluating theprogram to ensure that it is functional, of high-quality, and effective, and to help consider changes tothe program as needed in order to meet its objectives. The National CHW Program is also committedto using data for program planning and improvement at all levels. As such, program data shouldaddress program coverage, intensity, and quality, including quantity, quality, and impact of CHWservices. Additionally, program data should consider functionality of the National CHW Program,such as availability of finances and human resources, adequate and quality supportive supervision,functionality of the Technical Working Group and coordination efforts, and implementation of theNational CHW Strategy.

The National CHW Hub is responsible for ensuring that quality and timely data is collected, analysed,used, and disseminated at all levels of the program. The Hub will also conduct a comprehensiveprogram data review quarterly. Each district is responsible for reviewing CHW data collectedmonthly.

The National CHW Program is also committed to encouraging operational research to promoteinnovations that will strengthen the program. However, this operational research must be agreedupon by the Ministry of Health and Sanitation and work to strengthen the national program.Partners conducting operational research must work in close collaboration with the MOHS, in line

with official government policy and research objectives. This means, for example, researchquestions, objectives, and design must be cleared by the Ministry, and the MOHS ultimately ownsthe outcomes of the research.

Integrated CHW Data:

In order to ensure that CHW data is used coherently, cohesively, and effectively, the National CHWProgram collects data through a singular, harmonized data collection and reporting system, in linewith the national M & E system. Working with MOHS Department of Policy, Planning andInformation (DPPI), the program aligns its data system with the MOHS data system while alsoensuring that CHW data can be used by the National CHW Program to inform implementation,policy, and planning. CHW data must be included in the national reporting system, but the nationalCHW program ultimately owns the data. The National CHW Hub also works with DPPI to designreporting tools that support an enabling environment for CHWs. All tools must be user-friendly,aligned with CHWs’ scope of work, and supportive of their daily work.

All implementers (MOHS and IPs) must report based on the National M&E Framework3. Thisframework encompasses both CHW service delivery and operationalization of the national CHWprogram. There is one CHW reporting system and one national CHW register. All CHW data mustfollow the below reporting lines. This applies to both MOHS and IPs.

Roles and Responsibilities:

CHWs:

All CHWs are responsible for using the National CHW Register to collect data pertaining tothe full scope of the program at the community level. This data must be submitted on amonthly basis to peer supervisors.

All CHWs are also responsible for reporting weekly and monthly on Community-BasedSurveillance.

Peer Supervisors:

Peer supervisors are responsible for compiling data from their respective CHWs andreporting this to their respective PHU in-charge at the monthly CHW meeting at the PHU.

Peer supervisors are responsible for providing immediate feedback on data collected asneeded, particularly regarding quality, completeness, and timeliness.

Peer Supervisors must additionally work with existing community structures (e.g. VDCs andFMCs) to ensure that data analysed by the DHMT, IPs, and National CHW Hub is regularly fedback to affected communities.

PHU in-charges:

3 The National M&E Framework and a comprehensive M&E Plan is annexed to the 2016 National CHWStrategy.

PHU in-charges are responsible for compiling CHW reports and submitting compiledinformation to the DHMT.

PHU in-charges are also responsible for sharing analysed information, based on CHW data,with peer supervisors and CHWs at the monthly CHW meeting. This should be used toinform specific activities in a PHU catchment area and be selectively presented tocommunities, through existing community structures, to promote transparency,accountability, and behaviour change.

District CHW Focal:

The district CHW focal, working with the district M & E officer and implementing partner(s),is responsible for ensuring timeliness, quality, and completeness of the data submitted byPHUs. This data must be fed to the national system through the DHIS.

The district CHW focal, in collaboration with the implementing partner(s), is also responsiblefor analysing the data and presenting this data to the district TWG. This data will also bepresented at the monthly in-charges meeting, who are responsible for ensuring this datareaches Peer Supervisors and CHWs, and therefore ultimately communities.

While data within the district is ultimately owned by the DHMT, the district CHW focal isresponsible for coordinating with partners to ensure they have timely access to the datathey need. Any plans to collect data outside of the official national CHW program must becleared by the relevant DHMT and national CHW Hub. Resultant data must be shared withthe relevant DHMT and the national CHW Hub before being disseminated.

National CHW Hub:

The M & E office at the national CHW Hub is responsible for ensuring timeliness, quality, andcompleteness of data from districts to national and ensuring that CHW data is fullyintegrated into national HMIS.

The M & E Officer is also responsible for analysing, managing, disseminating, and ensuringutilization of national CHW data at all levels of the program.

Implementing Partners:

Implementing partners are responsible for ensuring data collection and reporting occurs atall levels and that the data is of high quality, complete, and timely. This could mean, but isnot limited to, providing spot checks of CHW data collection and of Peer Supervisorcollection of CHW data, as well as working with PHU in-charges to ensure data is reported tothe DHMT on time.

Implementing Partners must also assist with ensuring that analysed data is fed back tocommunities to promote evidence-based decision making and community ownership. Thiscould mean assisting with organizing community meetings; presenting data in a digestiblemanner to Peer Supervisors, CHWs, and community members; and working withcommunities to consider further activities based on data.

Implementing Partners can assist with analysis of data at district and national levels andusing data for decision making at both levels.

Implementing Partners are encouraged to consider operational research to help strengthenthe National CHW Program. This must be done in coordination with the MOHS.

Incentives and MotivationCHWs perform an essential, life-saving role in the health system. This role requires a substantialamount of CHWs’ productive time. For these reasons, it is necessary for CHWs to be paid for thiswork, both in recognition of its importance and in compensation for their lost time for other income-generating work.

The amount a CHW earns must take into account a variety of competing principles, priorities, andrealities. The National CHW Program and the MOHS believe that all health workers should ideally bepaid a living wage which reflects the value of their work and does not encourage them to engage incompeting activities to sustain themselves and their families. At the same time, the reality of thecurrent operating environment is one of severe resource constraints in which many trained andqualified health workers are working in post without being incorporated onto the payroll – i.e.operating as volunteers. The CHW program is currently funded by donors, and there is no budgetline for the CHW program in the GOSL budget; however the program’s ambition is to transition togovernment ownership and responsibility in the long term (25 to 30 years). Given this goal,sustainability of system is of concern, and the incentive for CHWs must represent coherence withsalaries of other health workers. While the minimum wage is set at Le 500,000 per month and this isthe salary that MCH Aides are intended to earn, the average income is Le 200,000 per month.Despite this, the Scope of Work outlined in the section above does represent close to full-time work.

Considering this contextual analysis, the National CHW Program has determined that CHWs mustearn at least Le 100,000 per month. This amount represents a minimum standard. This does notrepresent a living wage, and will impact CHWs’ ability to commit a full-time level of effort to theScope of Work. This policy does allow for (and encourage) flexibility to pay CHWs more dependingon the availability of resources. The process of determining variations in the financial incentive forCHWs will be described clearly in the National CHW Strategy, but will involve detailed analysis andagreement between the IP(s), the DHMT, the National CHW program, and other key stakeholders.The ambition of the program is to be able to pay a higher incentive in the future, however CHWs inthe National Program may not be paid less than Le 100,000 per month. The minimum standardmonthly incentive for Peer Supervisors is Le 150,000 per month.

Job Support for CHWs and Peer Supervisors

Bicycle or equivalent transport reimbursement4

Mobile phone with solar charger Airtime top-up5

ID card / badge Back pack T-shirt Rain gear Torch light (including batteries and replenishment) Pens / pencils

4 Rates to be outlined in the strategy or updated annually by the CHW Steering Committee5 Rates to be outlined in the strategy or updated annually by the CHW Steering Committee

Notebooks

Non-Financial Incentives

Awards for outstanding work (frequency and level to be outlined in the strategy) Encouragement of pursuing career pathways in the health system for those who meet the

minimum training requirements for those cadres Community leaders may mobilize their communities to provide support to CHWs, or exempt

CHWs from communal work. This will be negotiated on a per-community basis.

The package outlined above is a minimum standard. Additional non-financial incentives andmotivation may be offered by IPs, particularly to reflect innovative approaches to literacy, continuingprofessional development, and supplementing livelihoods. IPs must discuss their intendedinterventions with the DHMT (and/or National CHW Program / Steering Committee) for approvalbefore proceeding. Non-financial incentives should not compete with or take time away from theCHW Scope of Work.

High-performing Peer Supervisors may be encouraged to pursue career pathways into MOHS civilservice positions. CHWs will have access to a promotion pathway into the Peer Supervisor role, andpossibly into the MOHS after that.

Community EngagementCommunity ownership is a key component of any functioning CHW program. The National CHWProgram leadership is committed to ensuring strong local health structures and is committed tostrengthening those structures as part of the CHW program. CHWs, Peer Supervisors, PHUs, and IPsmust interact with existing local structures, and CHWs and Peer Supervisors are expected to be apart of them. Community health workers and peer supervisors are encouraged to contribute to thestrengthening of local structures that exist in their community, as well as their formation where theydo not already exist. This includes helping to organize meetings, encouraging communityparticipation, and facilitating community meetings as needed.

FMCs are the key community structure for health. In areas where FMCs exist and are functioning,they must act as the focal structure for their local CHW program. This means that FMCs areresponsible for overseeing the local CHW program, and that CHWs and peer supervisors should be apart of their local FMC. In areas where FMCs do not exist or are not functioning, CHWs must workwith the existing local structure.

VDCs are the key community development structure, of which health is a component. Where VDCsexist, CHWs and Peer Supervisors must work with them and encourage them to focus on communityhealth. CHWs and/or peer supervisors should be a member of their local VDC.

The DHMT, partnered with the IP(s), must work with PHU staff to inform local structures about theroles and responsibilities of CHWs, and local structures’ own roles in the CHW program. Localstructures are responsible for supporting the functionality of the CHW program in their community.They are specifically responsible for ensuring a strong relationship between the CHW and thegreater community, including accountability of the CHW to the community and mediating conflicts

between the CHW and the community. They are also responsible for supporting a strong relationshipbetween the CHW and the PHU (for example, approaching the PHU to address issues of CHWsexperiencing supply stock-outs). Local structures are also responsible for dissemination of data fromthe CHW program to the community and promoting healthy behaviour based on health indicators inthat community (see the M&E section of this policy for further guidance on this mechanism). Basedon the experience of the community, local structures can also express, to the DHMT, demand foradditional services from the local CHW program.

Local structures must participate in the selection, performance appraisal, and replacement of CHWs,as detailed in the Selection Criteria section of this policy.

CHWs are important actors in their community for social mobilization and health behaviour change.As part of this role, CHWs and Peer Supervisors must also work closely with other community socialmobilization and behaviour change structures, such as WASH committees, Mother-to-Mothersupport groups, Community Health Clubs, CAGs, etc. CHWs may serve as the secretary to thesegroups if they are literate and the group members are not; these groups may call upon the CHW tofollow up with a community member or family who has an identified health need within the CHW’sscope of work (for example, alerting the CHW if they come across a child who has a fever, or who issuspected to be malnourished); and CHWs can support these groups in their social mobilization andbehaviour change techniques and activities. Ensuring these partnerships is an important componentof the CHW’s role as a leader and change agent for improving health in their community.

Program Management and Coordinationa. Including Organogramb. Define structures / mechanismsc. Define roles and responsibilities of eachd. Mechanisms / structurese. Roles and Responsibilities of actors / stakeholders

The major stakeholders in the National CHW Program include the Directorate of Primary Health Care/ National CHW Hub; top MOHS leadership and management team; relevant MOHS programmanagers and directors; DHMTs; development partners; donors; IPs implementing the program; andtechnical partners. The National CHW Strategy will include a stakeholder mapping outlining the rolesand responsibilities of each of these actors. The following section outlines the key points related tothe actors most involved in management, coordination, and direct implementation of the program.

The National CHW Program will be managed by an MOHS-led Steering Committee. This committeewill be chaired by the Director of Primary Health Care, with the National CHW Hub serving as theSecretariat. Members will include other MOHS programs involved in CHWs’ work (for example, theNutrition Directorate; the Reproductive Health and Family Planning program; the Malaria, TB, andHIV programs; the M&E Unit). The committee will focus on coordination within relevant Ministryprograms and with other line ministries and donors. The Steering Committee will meet at leastquarterly to discuss coordination and implementation of the program, and more frequently asneeded. Development partners and implementing partners will not be standing members, but maybe invited to specific discussions as needed.

A National CHW Technical Working Group (TWG) is chaired by the Directorate of Primary HealthCare, with the National CHW Hub serving as the Secretariat. The CHW TWG is an open forum for allIPs, organizations, and relevant Ministry programs involved in CHW work. The Technicalcoordination and programmatic coordination. Review national program; review national andinternational evidence; offer policy guidance to the national CHW program; national CHW programdisseminate relevant information and offer implementation and policy guidance to IPs.

Roles and Responsibilities of the National CHW Hub include, but are not limited, to:

Providing leadership for an integrated, harmonized CHW program, including coordinationwith relevant programs/directorates and line ministries

Advocating for CHWs to be part of the National Health System Supportive supervision M & E and data management; data for decision making; data coordination Training CHWs, Peer Supervisors, and PHU staff Policy and strategy guidance and ensuring their implementation Financial planning, financing strategy, and resource mobilization

o Advocacy for financing for the National CHW Program with the MOHS / GOSLbudgets

o Coordinating and providing guidance to donors Ensuring CHW program is in alignment with MOHS strategies and priorities Guiding Research & Development by providing oversight and input into operations research

At the district level, the DHMT is responsible for overseeing coordination and implementation of theharmonized and integrated district CHW program. Specific roles and responsibilities of the DHMTinclude, but are not limited, to:

Implementation of the national CHW policy and strategy within the district Resource mobilization

o Working with Local Councils to mobilize local resources, including a line for the CHWprogram in the district budget

o Coordinate the use and distribution of IPs’ resources for coverage of the district Implementation planning, including coordinating between DHMT and IPs operating in the

district Maintaining an up-to-date district CHW database; registering and certifying all CHWs

operating in the district by maintaining a district database and providing ID Cards andCertificates

o DHMTs must conduct registration of CHWs as a joint exercise with IPs to ensurerecords are up-to-date and accurate, but the DHMT is ultimately responsible

Training of CHWs, Peer Supervisors, and PHU staff in the district Coordination through monthly District TWG / Coordinating Committee Supervision M&E, Data Management, and Data for decision-making Research & Development / overseeing the testing innovations Reporting to the National CHW Hub Determining appropriate coverage and distribution of CHWs in the district, and ensuring

implementation of the coverage and distribution guidance/ decisions

DHMTs are responsible for convening a District TWG or Coordinating Committee. Each districtTWG/CHW Coordinating Committee is responsible for coordinating between programs supportingCHWs and other community groups (Community Health Clubs, CAGS, M2M groups, etc.) to ensurecoordination, effective working and referral relationships, and address gaps and overlap in coverage(programmatic and geographic). The District TWG should include: DHMT, local councils, all IPsimplementing CHW programs in the district, relevant district-level MDAs. The District CHW FocalPoint, who is a member of both the CHW Hub and the DHMT, will serve as the Secretariat. TheDistrict TWG / Coordinating Committee is recommended to meet monthly when possible, but mustmeet at least once per quarter as a minimum. The responsibilities of the District TWG / Coordinatingcommittee include:

Review CHW activities (pegged to annual plans) Promote coordination between IPs Ensure DHMT oversight Ensure timely and accurate reporting of CHW registers and IP reports Address stock issues across the district Ensure CHWs are adequately supervised Utilize data to inform programmatic responses Ensure appropriate geographic coverage.

At the village level, local community structures (preferably the FMC, but could be the VDC or otherstructure as relevant per community) are responsible for coordination within their community, andfor reporting to the district TWG/CHW Coordinating Committee.

Implementing Partners will work together with the DHMT to implement the National CHW Program,in consideration of guidance from the national program and coordinated with the DHMT. The rolesand responsibilities of IPs include, but are not limited, to:

Alignment with the national CHW policy and strategy Coordinating budgeting and financing initiatives with district and national levels to avoid

duplication and address gaps Support the MOHS through the DHMT to roll out training (support can include financial,

human, logistical, technical, and other resources) Joint supportive supervision in conjunction with the DHMT Reporting on activities to the DHMT on a monthly basis Providing technical guidance and policy and strategy inputs to the MOHS through the

National and District TWGs

PHU staff are responsible for attending community meetings when possible, ideally at least on aquarterly basis, to promote a stronger link between the community, CHWs and PHUs.

Support to CHWs / Inputs Required

TrainingOverview:

The National CHW Program recognizes that robust and frequent training is essential to a strongprogram. A CHW program is only as strong as the competencies of its CHWs, and CHWs’competencies are often a direct result of the training they receive. High-quality, regular, andinteractive training is also a key motivator for CHWs, as well-trained CHWs feel empowered to dotheir jobs well.

The National CHW Hub is responsible for ensuring pre-service and refresher training of all CHWs andupdating the training model as needed. Any trainings not included in the national pre-service andrefresher training must be agreed upon by the National CHW Hub, with MOHS staff attending allCHW trainings.

The trainings must be competency-based and skills-based, and focus extensively on providing hands-on experience and practical experience to CHWs, including by training CHWs in the field or insituations which mimic the field. It is also important to note that training is not effective withoutfrequent and quality supportive supervision throughout training and immediately following training,as this is when mistakes are most likely to be made while behaviour also most easily modified. Allstakeholders in the National CHW Program therefore have a responsibility to ensure supportivesupervision occurs throughout and immediately following trainings.

For all trainings, all CHWs will be required to do a pre- and post-test to help determine theircompetencies and ability to learn.

All Peer Supervisors must go through the same training program as CHWs, as it is important forsupervisors to fully understand the roles and competencies required from those they supervise.However, Peer Supervisors must also be adequately trained specifically in supervision with a strongfocus on effective communication, data collection and reporting, and spot-checks that test quality ofCHWs’ work, mentoring and coaching.

Modality:

The National CHW Program uses a cascade model. A core group of facilitators, including of MOHSstaff (senior staff from relevant programs and directorates, for example RCH, DPC, Surveillance,Malaria, Child Health, Nutrition, etc.), development partners and implementing partners aretogether responsible for conducting a Master Trainers’ TOT, which will train the National CHW Hub(Regional Coordinators), senior CHOs, national M&E officers from DPPI, Development Partnersnational staff (i.e. UNICEF), and national staff from select IPs implementing the national program.Master trainers are then responsible for cascading the training to districts, including the DistrictCHW Focal and 3 other DHMT staff, chiefdom supervisors, and IP district level staff.

District trainers train CHWs directly at the chiefdom level. CHWs in one chiefdom are assembled atthe chiefdom headquarter town, and the training is conducted by the chiefdom supervisor, DHMTand IP staff, with support from national trainers and participation of PHU staff. Master Trainers(national MOHS and IPs) are responsible for ensuring high quality and consistent training andsupportive supervision throughout the cascade model.

While training for the National CHW Program is primarily the responsibility of the MOHS,implementing partners can play an important role in achieving national scale and ensuring qualityand consistency. Implementing Partners may be especially helpful in providing additional human

resources, both for conducting trainings and providing intensive supportive supervision throughoutand immediately following trainings. They can also prove helpful in identifying gaps in training andpotential need for refresher or disease-specific trainings. However, both Implementing Partners andMOHS structures outside of the National CHW Hub should never conduct trainings outside of theNational CHW Program unless this is expressly agreed upon by the DHMTs and the National CHWHub. The National CHW Program does recognize that additional trainings can act as a key motivatorfor high-performing CHWs and does not discourage additional trainings, either by the MOHS orimplementing partners, but does require that all trainings be vetted through the National CHW Hub.

Drugs, Health Commodities, Supply Chain, LogisticsThe supply chain has a significant impact on CHWs’ motivation. When CHWs have the drugs,commodities, and supplies they need to do their jobs, they are empowered and more confident intheir work. When CHWs experience frequent stock-outs, they are not able to perform their roles andthis contributes significantly to demotivation in the program.

The national supply chain system is responsible for ensuring adequate drugs and supplies arequantified and distributed to CHWs for their work. The District Medical Stores are responsible forincorporating CHW supply needs into district quantifications, and including CHWs supplies indistributions to PHUs. PHU staff are responsible for providing supplies to CHWs at their monthlymeetings at the PHU. CHWs are responsible for submitting utilization reports.

In reality, the supply chain system in Sierra Leone is weak at all levels, and due to this, many IPs havehistorically procured and provided buffer stocks of drugs and supplies to CHWs to fill gaps andprevent stock-outs. While this is not encouraged as a long-term solution, the National CHW Programdoes recognize that this happens and the reasons why. In cases where an IP determines a need toprovide buffer stocks, they are encouraged to provide these commodities to the District MedicalStore, and work with the DMS and PHUs to ensure the appropriate proportion of all district and PHUsupplies reach CHWs. Partners and DHMTs are required to send reports regarding these extrasupplies to the NPPU so these ‘top-up’ needs can be taken into account to support properquantification going forward. Partners should not provide supplies directly to CHWs in a manner thatcircumvents the national supply system.

The National CHW Program is responsible for providing service coverage data, including drug andsupply utilization, to NPPU to inform quantification, for drugs and supplies covered by the FreeHealth Care Initiative. For any drugs and supplies not covered by the Free Health Care Initiative, theNational CHW Program is responsible for conducting quantification, based on data provided by thedistrict focal points. The National CHW program will also advocate for these supplies to bequantified, procured, and distributed through the NPPU as national supply chain functionalityimproves and to support the objectives of integration (i.e. that these items should be incorporatedinto the national supplies list).

Peer Supervisors are responsible for monitoring CHWs’ stocks and are the first point of contact forCHWs to report stock-outs. Peer Supervisors should work with community structures (ex. FMCs,VDCs, or other health-related structures in the particular community) to address any conflictbetween PHU staff and CHWs on allocation of drugs and supplies / stock-outs.

All services, including drugs, provided through the National CHW Program are provided free ofcharge. Clients must never be asked to pay for services and drugs provided by CHWs; any reports ofclients being charged a fee for services, including drugs, from CHWs will be investigated and dealtwith seriously.

District Coordinators’ role in ensuring that PHUs consistently and appropriately provide the 30%allocation of drugs to CHWs, and for feeding more robust consumption and coverage data toDMS/DLO and the National CHW program to refine allocation proportions in future policy, strategy,and implementation.

The following supplies are required as a minimum for each CHW to be able to perform their Scope ofWork6:

iCCMo ARI timero MUAC stripo RDTo Antibiotics7

o ORSo Zinco Artemisin-based Combination Therapy

Family Planningo Condomso Oral Contraceptive Pills

CBSo Reporting tools

MNH, WASH, and Health Promotiono Job aids / counselling cardso Monitoring forms / reporting tools / Registero Household Checklisto Household Planning Cardo Health Promotion and Communication Tools

IPCo Medicine boxo Sharps containero Soap / hand sanitizero Gloveso N-95 Mask for TB CHWs

For any additional scope of work, CHWs must receive the supplies and commodities required.

Quantification of Supplies:

6 Supplies subject to change based on alterations to Scope of Work and international and national guidelinesand best practice7 Specific antibiotics to be determined based on current national and international guidelines.

Quantification of the drug supplies provided by PHUs to CHWs should ideally be based onconsumption data that records which drugs and commodities have been used by whom and at whichlevel (community, PHU, etc.). However, at the time of writing this policy, this data is not alwaysreadily available. RRIV forms (forms used by PHUs to report on drug and supply consumption) areoften incomplete, late, or not submitted at all. There are also known tensions between PHU staffand CHWs caused by an absolute scarcity of drugs and supplies in the system, and low functionalityof the supply chain system nationally. This is due to both the reporting challenges described above,as well as the continuing use of the ‘push’ system of quantification and distribution at the time ofpolicy writing. For these reasons, the guidance provided in the past for provision of drugs andsupplies from PHUs to CHWs has been based on morbidity data. As such, CHWs are expected to beprovided with 30% of the drugs and supplies allocated to each PHU, with 70% remaining for use bythe PHU staff. Until higher quality and disaggregated consumption data is available, thisrecommendation remains the default. DHMTs are responsible for factoring in CHWs’ supply andcommodity needs when doing annual and quarterly quantifications, ordering, and utilizationreporting.

Further guidance on responsible parties for ensuring CHW supplies and inputs to be considered indetermining total number of supplies is outlined in the 2016 National CHW Strategy.

Accountability For Supplies

CHWs are accountable for the drugs, commodities, and supplies they receive. Through the CHWRegister, they must account for the supplies they have disbursed in order to receive areplenishment. CHWs who do not properly account for utilization will not be replenished.

Equally, PHU staff are accountable for ensuring CHWs receive the supplies that are intended forcommunity use, at the proportional level defined above (30% of the PHU allocation). PeerSupervisors are responsible for ensuring that CHWs receive the supplies allocated to them from thePHU and that CHWs properly report on their supply usage. Disputes over supplies should bereported to the District CHW Focal, who can be supported by the Implementing Partner and NationalCHW Hub as needed.

Urban CHWs

OverviewThe National CHW program recognizes that urban areas are distinct from the rest of Sierra Leone.From the perspective of health outcomes, health access, and the need for a CHW program, thesedifferences concern access to PHUs, population density, and geography/terrain.

Taken together, these factors beget a different CHW program suited to an urban population’s needs.Recognizing this, but equally recognizing that urban communities continue to have poor healthindicators, low utilization of facility-based health services, and practice poor health behaviours,Urban CHWs (uCHWs) focus exclusively on behaviour change and promoting facility uptake throughreferrals and community sensitization; they do not do iCCM. Because of their more limited scope ofwork, uCHWs have not historically received any incentives, including transport reimbursement, andare not expected to provide services to as many households, compared to CHWs in the rest of the

country. In the revised CHW program, uCHWs will additionally be required to conduct Community-Based Surveillance, and will receive a minimum standard incentive as compensation for their work.Additionally, the National CHW Program will support an associated HIV and TB community-basedprogram that provides essential services, through a peer-to-peer approach, in high-burden areas.Urban populations has some of the highest rates of HIV and TB in Sierra Leone, and as such, theNational CHW Program will support a significant HIV and TB community-based program in these andother high-burden areas in conjunction with the National TB/Leprosy Control Program and NationalAIDS Control Program. These services will be provided in a peer-to-peer model delivered by peopleaffected by the diseases they are addressing through their work, which is a separate delivery systemthan that of urban CHWs services, but will be closely coordinated at an administrative level withinthe MOHS.

The below highlights distinctions between the National CHWs and uCHWs. Areas not specified below(such as Supervision and Selection) will remain the same as the National CHW Program.

Scope of Work Community sensitization for behaviour change

o Preventive and promotive behaviours for maternal, neonatal, child health, includingWASH, IYCF, FP, immunization

ANC and PNC Home visits to promote uptake of facility based care during pregnancy,delivery and postnatal period

o Identify danger signs in pregnancy and postnatal period (mother and newborn)o Promotion of Essential Newborn Care (education through ANC, very basic

preparedness for births that take place in the community despite encouragement offacility births)

o Provide IPTp Report birth, maternal and under five deaths in the community Family Planning: Condom distribution and refill birth control pills Social mobilization for specialized campaigns (examples: Welbodi Weeks (MCH Week),

National Immunization Days (NIDs), bed net distribution) Sensitization of communities about

o TB risk factors, signs and symptoms, referral for testingo HIV risk factors, signs and symptoms, referral for testing

Disease Prevention and Control: Community-IDSR (CBS): Surveillance and reporting of anyevents related to the following diseases / conditions:

o Acute Flaccid Paralysis (Polio)o Acute Watery Diarrhoeao Clustered deathso Guinea Wormo Maternal Deatho Measleso Neonatal Tetanuso Neonatal Deatho Suspected Ebolao Yellow Fever

Incentives and Motivation

uCHWs must receive a minimum standard financial incentive of Le80,000 a month. Peer Supervisorssupporting uCHWs must receive a minimum standard incentive of Le100,000 a month. Both uCHWsand uPeer Supervisors must receive Le20,000 for any additional work (such as campaigns) thatrequires more than a five-hour time period. Both uCHWs and uPeer Supervisors must receive theminimum non-financial incentives outlined in the National CHW Policy and National CHW Strategy;however, it is not appropriate for them to receive bicycles for transportation given the terrain,population density, and transport accessibility within urban areas.

Coverage

While the National CHW Program recommends a CHW : population ratio of 1 CHW : 100-500 people,the uCHWs recommends a ratio of 1 CHW : 1,000 individuals. As is true in the National CHWProgram, the ratio will vary community by community, depending on a variety of inputs outlined inthe “Coverage” section of this policy. The DHMT is responsible for considering these inputs anddetermining final coverage ratio per community. This effort should be led by the District CHW FocalPoint, in close collaboration with the District Council and IPs, and with support from the NationalCHW Hub.