Reference_Nigeria Community Health Workers Program Guide.pdf

A publication of the National Primary Health Care Development Agency, Abuja, Nigeria. August 2024 For more information contact:

Dr Muyi Aina, Executive Director/Chief Executive Officer, NPHCDA, Plot 681, Port Harcourt Cresent, Garki, Abuja

LIST OF CONTRIBUTORS

NPHCDA

1. Dr. Muyi Aina , Executive Director /Chief Executive Officer

2. Dr. Ngozi Nwosu , DPHCSD/Consultant Special Grade 1

3. Dr. Maimuna Hamisu, Director CHS

4. Mr. Adeniyi Ekisola, Deputy Director, HSS

5. Pharm. Mohammed A. Mohammed, Deputy Director, HF

6. Dr. Nana Sandah-Abubakar, Deputy

Director, CHS

7. Dr. Amina Abdullahi , Deputy Director, HRH

8. Mrs. Ohifeme Adeola, Deputy

Director, HRH

9. Dr. Kasarachi Aluka-Omitiran , Deputy

Director, CHS/Consultant Special Grade II, CHS

10. Dr. Muhammad Bello Garba , Deputy Director, /Consultant Special Grade II, CHS

11. Dr. Amina Ahmed Abdullahi , Senior Medical Officer, CHS

12. Dr. Hafsah Othman , Senior Medical Officer II, CHS

13. Miss. Ononuju Okonkwo , Assistant Chief Scientific Officer, CHS

14. Mrs. Ndidi Molokwu , Assistant Chief Planning Officer

15. Mr. Wright R. Emonefe , Senior Scientific Officer, CHS

ED’s Office

16. Ms. Itoro Ita , Senior Technical Adviser

17. Dr. Aqqad Aliyu Tilde Technical

Assistant

Community Health Practitioner Registration Board of Nigeria

18. Mrs. Patience Tanko Achi

19. Mr. Saleh Isa

Partners

20. Dr. Sylvester Akande, USAID

21. Mrs. Olamide Akeboi , Corona

Management Systems

22. Dr. Victor Ochagu, African CDC

23. Mr. Ogbodo Ikechukwu , Solina

24. Mrs. Lilian Adeogba , IFRC

25. Dr. Manir H. Jega, NRCS

26. Dr. Godwin Gana , World Bank

27. Mr. Chinua Nzelibe, Corona

Management Systems

28. Mr. Abolade Oyelere , HSDF/ HSSA

29. Dr. Olayinka Ilesanmi , Africa CDC

30. Mr. Umar Kabo Idris, Results for

Development/HSSA

31. Dr. Chiamaka Momah-Haruna , World

Bank

32. Dr. Grace Nwankwo, USAID/ PMI

33. Mrs. Foyeke Adebagbo, USAID

34. Dr. Victoria Isirami , UNICEF

35. Dr. Khalilu Muhammad , BMGF

36. Dr. Raihanah Ibrahim , Solina

37. Dr. Fatimah Cheshi , UNICEF

38. Dr. Chijioke Kaduru , Corona

Management Systems

39. Mrs. Nelly Ale , Mastercard Foundation

40. Dr. Ritgak Tilley-Gyado , World Bank

Secretariat

41. Miss. Nwaze Uchechi Eunice, Community Development Officer 1

42. Mrs. Udeme Ekerete , Chief

Confidential Secretary

43. Mr. Idume Ogbonna, ICT

Consultants Prof Clara Ladi Ejembi

Dr. M.J Abdullahi

TABLE OF CONTENTS

Contents LIST OF CONTRIBUTORS ii

TABLE OF CONTENTS iii

LIST OF TABLES iii

LIST OF FIGURES iii

FOREWARD iv

ACKNOWLEDGEMENTS vi

ACRONYMS vii

1. INTRODUCTION 1

1.1. Background 1

1.2. Justification 2

1.3. Goal and Objectives 3

2. CONCEPTUAL FRAMEWORK 3

2.1. Concept of the Community Based Health Workers 3

2.2. Strategic Approach 4

3. THE COMMUNITY BASED HEALTH PERSONNEL 5

3.1. Scope of Work 5

3.2. Selection and Recruitment 7

3.2.1 Selection Criteria 8

3.2.2 Nomination and Screening Process for Auxiliary CBHW 8

3.2.3 Validation of the JCHEWs 9

3.3. Distribution of the CBHW 9

3.4. Incentives and Compensations 10

3.4.1 Financial Compensation 10

3.4.2 Non-financial Compensation 10

4. IMPLEMENTATION 11

4.1 Implementation Plan 11

4.2 Training 13

4.2.1. Outline of the Training Modules 14

4.2.2. Approaches to the Training and Retraining Process 16

4.2.3 Methodology of Training and Training Resources 18

4.2.3. Accreditation 19

4.3 Community Mapping and Deployment 19

4.4 Service Provision 20

4.4.1 Service delivery mode and conduct of work 20

4.4.2 Estimated work output 23

4.4.3 Record keeping 25

4.5 Supervision 26

4.5.1 CBHW Supervision 26

4.5.2 Supervision of implementation 27

5. MONITORING AND EVALUATION 28

5.1 M&E Framework 28

5.2 Monitoring 29

5.3 Evaluation 31

6. MANAGEMENT 32

6.1 Governance 32

6.1.1 Governance and Coordination 33

6.1.2 Roles and Responsibilities 34

6.1.3 Stakeholder Engagement 35

6.2 Commodity Supply Chain 36

6.3 Resource Requirements and Management 36

7. BUDGET 37

7.1 Estimated Budget 37

7.2 Sources of Funds and Resource Mobilization Plan 39

BIBLIOGRAPHY 41

APPENDICES 44

Appendix 1: Commodities and Equipment needed for the 44

Appendix 2: Rewards and Sanctions 45

Appendix 3: Key Performance Indicators 48

Appendix 4: Stakeholder engagement strategy 49

LIST OF TABLES

Table 1: Dimensions for the Redesign of the Community Health Workers Table 2: Scope of work of the Community Based Health Workers Table 3: Phased coverage of community-based health worker Table 4: CBHW implementation process Table 5: Outline of the Training Manual for the CBHWs Table 6: Modules for the Training Manual for the Supervisors of CBHWs Table 7: Accreditation Process for both JCHEWs and Auxiliary CBHWs Table 8: Basic Package of Services Table 9: Comprehensive Service Delivery Pack Table 10: Organisation and conduct of work at different levels.

Table 11: Roles and Responsibilities of the different stakeholders Table 12: Cost estimates for the CBHW implementation Table 13: Population parameters for computing population in need of essential commodities for CBHW

LIST OF FIGURES

Figure 1: Framework for Community-Based Service Delivery and Demand Generation in a Ward by Community-Based Health Workers Figure 2: Training cascade for the community health workforce

Figure 3: Logic Framework for M&E

FOREWARD

Nigeria has made several attempts to improve the health of its citizens, however, despite the laudable attempts, population health indices remain poor. Maternal and child mortality rates rank amongst the highest globally, with access to health care especially in underserved and rural areas severely limited. The poor mortality and morbidity indices are largely as a result of low and inequitable coverage with high-impact interventions and poor demand for services due to weaknesses in the healthcare delivery system.

Primary health care development is key to improving population health and achieving universal health coverage. We need to invest in strengthening our PHC system, especially the community component.

People and communities lie at the heart of health system strengthening, within the context PHC, as the foundation for universal health coverage. Innovative strategies for community health programming are needed to ensure access to essential healthcare services for the Nigerian population, emphasizing equitable access and coverage with high-impact community interventions. These strategies must take into context and improve on the challenges of previous community health programmes while ensuring there is co-creation with sub-national levels to ensure programme ownership.

This current strategy emerges from a deep understanding that effective health interventions must be rooted in the unique needs and strengths of our local populations.

Noteworthy in achieving these aspirations is the calibre of the health workforce deployed. To ensure high-quality services are delivered at the community level, we must begin to transition from utilizing lay health workers to professionalized, competent, salaried healthcare workers

This strategy outlines a comprehensive framework that encompasses recruitment, training and deployment of appropriate health workers, the spectrum of services to be provided at community level as well as governance and monitoring and evaluation systems. By leveraging data-driven insights and fostering cross-sector collaboration, we aim to address health disparities and promote wellness in a manner that is both sustainable and impactful.

Our vision is clear: to create environments where health is not just the absence of illness, but a state of complete physical, mental, and social well-being. As we embark on this transformative journey, we remain steadfast in our commitment to innovation, compassion, and resilience. We hope that this new “blended” model of Community Health Workers Programme in Nigeria will ultimately lead to an improvement in the overall health indices in Nigeria.

Dr Muyi Aina, ED/ CEO, NPHCDA

ACKNOWLEDGEMENTS

The remodeling the Community - Based Health Worker Programme to strengthen the community component of Primary Health Care for improved population health outcomes in Nigeria was a product of collaborative efforts by different stakeholders in the PHC space.

The development of the Implementation Guide for the revised programme is one of the key outcomes of this well-coordinated process led by the NPHCDA.

In recognition of the depth of contributions and profound zeal shown by the different stakeholders in the restructuring process, the National Primary Health Care Development Agency is highly appreciative of the guidance of the Federal Ministry of Health and Social and Welfare, the great support from Community Health Practitioners’ Registration Board of Nigeria and our Partners. The Agency is also particularly grateful to the United States Agency for International Development, World Health Organization, United Nation Children’s Fund, The World Bank, Clinton Health Access Initiative, African Union, Afican Centre for Disease Control, Health Service Delivery Foundation, Results for Development, Solina Centre for International Development and Research, MasterCard Foundation, Corona Management Systems and a host of other partners that supported this project.

Our special appreciation and gratitude also go to Dr Maimuna Hamisu, Director, Community Health Services, Dr Nana Sanda Abubakar, Dr MJ Abdullahi, colleagues in the Departments of Community Health Service and Primary Health Care Systems Development as well as Office of the Executive Director. We particularly appreciate the commitment and enthusiasm shown by the following individuals in drafting the Programme Guide: Dr Muhammad Bello Garba, Dr Kasarachi Aluka Omitiran, Dr Amina Ahmed Abdullahi, Dr. Hafsah Othman, Ms.

Omouju Okonkwo, Dr Godwin Gana and Mr. Raphael Wright Emonefe. The invaluable contributions of Prof Clara Ladi Ejembi in guiding and coordinating the processes of revising the strategy and developing this document is worthy of note and appreciation.

Finally, our profound gratitude goes to the Executive Director and Chief Executive Officer of the NPHCDA for providing the leadership, guidance and support that facilitated the successful conduct of the exercise that led to development of the Revised Strategy and the Programme Guide.

Dr Ngozi Nwosu

Director, Primary Health Care System Development

ACRONYMS

ACBHW Auxillary Community Health Worker AEFI Adverse Events Following Immunisation AIDS Acquired Immuno-deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Illnesses CBHW Community-based Health Worker CBO Community Based Organisation CEFP Community Engagement Focal Person CHEW Community Health Extension Worker CHIPS Community Health Influencers, Promoters, Services CHO Community Health Officer CHPRBN Community Health Practitioners’ Registration Board of Nigeria CMPDSR Community Maternal and Perinatal Death Surveillance and Response CORPS Community-Oriented Resource Persons DHIS District Health Information System DOTS Directly Observed Treatment Service FBO Faith Based Organisation FP Focal Person HH Household HIV Human Immunodeficiency Virus HTR Hard to Reach ICCM Integrated Community Case Management ISS |Integrated Supportive Supervision JCHEW Junior Community Health Extension Worker LGA Local Government Area LGAHMT Local Government Area Health Management Team LLIN Long Lasting Insecticide Treated nets M&E Monitoring and Evaluation MDA Ministries, Departments and Agencies MICS Multiple Indicator Cluster Survey MNCH Maternal, Neonatal and Child Health MPDSR Maternal and Perinatal Death Surveillance and esponse NCD Non-Communicable Diseases NCHMIS National Community Health Management Information System NGO Non-Governmental Organisation NPHCDA National Primary Health care Development Agency NpopC National Population Commission OiC Officer in Charge PBI Performance based Incentives PHC Primary Health Care PNC Post Natal Care RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health SHT School of Health Technology SMOH State Ministry of Health SPHCDA/B State Primary Health Care Development Agency/Board TB Tuberculosis UHC Universal Health Coverage VCM Volunteer Community Mobilisers WASH Water, Sanitation and Hygiene WDC Ward Development Committee WRAG Women of Reproductive Age Group

1. INTRODUCTION

1.1. Background

Nigeria has some of the worst health outcomes in the world for both women and children.

Pneumonia, malaria, and diarrhoea combined account for a million deaths in children annually, while 33,000 mothers die from pregnancy-related causes. These figures account for 14% and 11%, respectively, of the yearly global deaths of mothers and children. Poor coverage of high-impact interventions, health inequities, barriers to accessing health care and lack of awareness of service availability are among the main contributing factors to the high rates of maternal and infant mortality, and majority of these deaths are largely preventable.

Inequities in access to and coverage of health services contribute unduly to the health outcomes. The poor and rural communities and other socially disadvantaged groups have disproportionately poorer access to health services despite their higher burden of disease and deaths compared to their wealthier and urban counterparts. In these underserved communities, demand and utilization of PHC services remain low because of persistent systemic weaknesses. Alternative health services from private health facilities are expensive – making them economically inaccessible to poor households.

This results in vulnerable underserved populations resorting to sub-optimal care from informal private healthcare service providers including patent medicine vendors and traditional healers. Additionally, because of ignorance, individual households usually delay decisions on care-seeking.

Evidence has shown that the attainment of Sustainable Development Goal 3 and Universal Health Coverage (UHC) depend heavily on primary health care, which is the cornerstone of Nigeria's health policy and the foundation of its health system. It is important to note that the Primary Health Care System in Nigeria comprises two levels:

the PHC facility and the community. It is increasingly being recognized that attainment of UHC is not feasible without investment in the community component of primary health care that seeks to expand access to underserved populations.

Nationally, several attempts have been made to strengthen the community component of Primary Health Care, the most recent being the implementation of the Community Health Influencers Promoters and Service (CHIPS) , which commenced in 2018, spearheaded by the National Primary Health Care Development Agency, in line with its mandate to strengthen the Village Health Worker . The overall goal of the was to contribute to the reduction of maternal and child morbidity and mortality by improving access to and equitably increasing coverage of basic primary health care services, especially relating to maternal and child health, including improved access to treatment for common childhood illnesses, and increasing demand for services. The also attempted to integrate and harmonize all vertical community-based health s for improved and efficient coordination, implementation and outcomes. The operational unit for planning was the ward and the personnel used were the CHIPS Agents, who provided service through home visits and Community Engagement Focal Persons who supported the CHIPS Agents with data collation and transmission and engaged males in the communities to address constrains to PHC services uptake. The proposed a minimum of 10 CHIPS Agents and two CEFPs per ward. The CHIPS agents were linked to ward PHC facilities for referrals, collection of drugs and supervision. The key principles of the were volunteerism and harmonization/integration of community-based workforce and s. An economic empowerment component was added to provide the volunteer workers a means of livelihood. The was launched by the then President in 2018, and by 2023, all the states of the federation had started implementation of the , albeit, at different levels by 2023. A total of 18,559 CHIPS Agents and 3,493 Community Engagement Focal Persons had been trained, with 12,986 CHIPS Agents providing service across 26% of the wards in the country.

Following several calls to optimize and strengthen the community component of Primary

Health Care, a redesigned community-based health workforce will be implemented to achieve this.

1.2. Justification

To improve critical health outcomes in Nigeria, the community health system has a key role to play, and sustained efforts to strengthen the community health and the primary health care systems they lean on must be made. At the heart of a high-performing and functional community health system lies a resilient community-based health workforce.

The right cadre of workers must be recruited, adequately trained and equipped to provide services, appropriately remunerated with clear career development pathways and supportive working environments in line with sub-national contextual realities.

Accordingly, and in line with the Honourable Coordinating Minister of Health and Social Welfare’s National Health Sector Renewal Investment , NPHCDA’s strategic blueprint and feedback from the sub-national levels, there was a need to review and restructure the existing community-based health workforce model to ensure there is better alignment for the delivery of expected outcomes. This review revealed poor political commitment and ownership at the subnational level, grossly inadequate funding, capacity gaps and poor motivation of the CHIPS personnel, gaps in the supply chain for commodities and inadequate supportive supervision systems as key challenges to the optimal performance of the . Additionally, there were concerns about the competence of the CHIPS Agents to provide treatment and dispense drugs, and that the community health extension workers are better placed to provide these services, as they have been professionally trained for the role. Following the identification of these challenges and gaps, the Management of NPHCDA and their partners have redesigned the community-based health workforce to ensure a national that delivers on the intended outcomes, address the identified gaps with the CHIPS , while taking into contextual local realities and promoting state ownership in its implementation.

1.3. Goal and Objectives

The goal is to ensure the availability of a sustainable community-based health workforce model that will provide quality health services within Nigerian communities, leading to equitably expanding access to and demand for quality health services, thus increasing service coverage and ultimately improved RMNCAH and other health outcomes.

The goal of the redesigned will be achieved through the following:

1. Adoption of a blended CBHW model comprising a mix of formally trained, certified and regulated Junior community health Extension Workers (JCHEWs) and informal Auxiliary community health workers recruited the communities they will work in.

2. Deployment of a dedicated culturally competent, trained and equipped community health workforce who are linked to PHCs to deliver services through home visits to households while strengthening the community health system.

3. Generation of demand for PHC service for increased utilisation of facility level services.

4. Integration of service provision at the community level for enhanced effectiveness, efficiency and impact

2. CONCEPTUAL FRAMEWORK

2.1. Concept of the Community Based Health Workers

The Federal Government of Nigeria has initiated a redesign of the Community Based Health Worker (CBHW) to improve on the former CHIPS for the acceleration attainment of Universal Health Coverage. Community Based Health Workers play a vital role in health promotion, disease prevention, provision of basic services and demand generation. Because they link community members to available health facility services, there is a need for a more inclusive approach to their roles and work ethics.

Supported by global evidence, two cadres of community-based health workers will provide health services at the household level within the community and will initially focus on priority health s and health system strengthening activities, ranging from simple promotion (e.g., informing pregnant women about ANC) to more complex treatment services (e.g., administering DOTS for TB).

Nigeria’s evolving community level PHC landscape supports a model where both Junior Community Health Extension Workers (JCHEWs) and Auxiliary Community Health Workers (ACBHW) will be employed to provide a broad set of services in which the skilled and formally trained JCHEWs deliver more complex prevention, diagnosis, and simple curative services.

● Skilled unemployed CBHWs (JCHEWs) are available for quick deployment to communities to provide services.

● Less skilled and informally trained Auxiliary CBHWs (ACBHW) (such as the CHIPS Personnel, VCMs, CORPs etc) will be upskilled to provide simple health promotive, preventive and basic curative services, where the former is not available.

The provision of a range of quality health care services at the community level will complement the facility services. Four health outcomes have been prioritized for improvement: RMNCH and Nutrition; immunizations for priority antigens; slowing down the prevalence of NCD and reduction in the incidence of HIV, TB, and malaria.

2.2. Strategic Approach

A minimum of 10 CBHWs per ward will be recruited, trained, deployed, mentored, and supervised. The ratio of the JCHEWs to ACBHW per ward will be determined by the states based on the availability of either cadre and availability of resources for efficient, effective, and sustainable implementation. The technical supervisors shall be the CHEWs, CHOs, or Midwives in the focal health facility. The Ward Development Committees (WDCs) shall provide oversight alongside other identified stakeholders for the non-technical supervision and other implementation support, including community involvement. (Figure x below).

The framework envisions increased access to essential health care along a continuum of care from the households within the community to the PHC facilities and referral to secondary health facilities. It requires revitalization of the PHC facilities for improved service delivery and strengthened wider system support (financial, procurement and supply chain, data and referral systems) to address the supply side challenges and achieve the desired goal.

Figure 1: Framework for Community-Based Service Delivery and Demand Generation in a Ward by Community-Based Health Workers

The redesigned CBHWs will be implemented along 12 dimensions (roles, profiles and responsibilities, governance, financing, supervision, supplies and tools, data collection & use, community involvement, remuneration and incentives, training, accreditation, recruitment and placement, and career advancement) across three domains (Strategic, operational and workforce development). Table 1 briefly describes the dimensions.

Table 1: Dimensions for the Redesign of the Community Health Workers

3. THE COMMUNITY BASED HEALTH PERSONNEL

3.1. Scope of Work

Service provision at the community level will initially focus on priority health s and health system strengthening activities, within a wide range of promotive, preventive and basic curative services. As such, community-based health workers (CBHWs) serve as the link between households and communities to health facilities, facilitating the uptake of integrated PHC services.

The scope of work delineates the responsibilities of the CBHWs at household and community level within this framework, as described in Table 2

Table 2: Scope of work of the Community Based Health Workers

Activity Description Add-on for JCHEWs

Community Mapping

● Conduct community mapping, household numbering and collection of basic demographic information on all members of households in the assigned practice area for identification of target groups.

● None

Health promotion and demand creation

Conduct home visits to:

● Promote appropriate health care seeking and positive health care behaviour

● Create demand for health services and mobilise the communities for outreaches

● Provide health education and counselling on:

- Child Health services e.g. immunisation and nutrition

- Maternal and Newborn Health Services e.g. ANC/Delivery

- Water, sanitation & hygiene (WASH)

- Reproductive, Sexual and Adolescent Health

- Nutrition

- Family planning

- Communicable diseases e.g. HIV, TB, Hepatitis, Malaria prevention

- Non-Communicable diseases e.g. Diabetes, hypertension – prevention and healthy lifestyles

- Care of the elderly, disabled and people living with mental health disorders

● Inform target populations of the services available in the PHC facilities, identify the target groups for the various services such as childhood immunization, antenatal, delivery and post-natal care, and encourage uptake of the services counsel and encourage them to avail themselves of the services.

● Facilitate referrals and link the populations to the health facilities to access the appropriate care and provide follow-up care.

● Encourage enrollment into health insurance schemes.

● Encourage male support and participation

● Provide health education on nutrition and conducting food demonstration sessions

Integrated Community Case Management

Provide disease specific care for the sick child:

● Identify and refer children newborns and children aged 2 – 59 months with danger signs and refer immediately, after giving pre-referral treatment, as appropriate.

● Identify, assess and treat children aged 2 – 59 months with simple malaria, acute respiratory tract infection (ARI) and diarrhea.

● Identify children with severe acute malnutrition and refer to CMAN centres and provide nutrition counseling for children with moderate malnutrition.

None

Activity Description Add-on for JCHEWs

Other Treatment services

● Provide first services and refer as appropriate.

Continuity of care for essential services and community hdistribution of commodities

● Administer albendazole to children underage of 5.

● Distribute misoprostol for pregnant women.

● Distribute chlorhexidine gel for cord care in newborns.

● Refer pregnant women with danger signs

● Refill oral contraceptives for women of reproductive age group (WRAG) and medicines for stable hypertensive, tuberculosis and HIV/AIDS patients.

● Provide community-based immunisation services.

● Refill anti-hypertensive and anti-diabetic drugs for stable patients receiving care at the focal facility

Screening for important health conditions

● Screening for eligibility for contraceptives

● Screening for hypertension and diabetes mellitus

Surveillance and epidemic response

● Identify, monitor and report :

- Notifiable diseases, especially public health emergencies

- Maternal, perinatal and child deaths

- Child health issues e.g. Immunisation, Nutrition

- Health problems relating to HIV/TB/Hepatitis/NCD

● Actively participation in the community maternal, perinatal and child deaths surveillance and response (identification and reporting, verbal and social autopsies and monitoring of implementation of community action plans), risk communication and community engagement within the epidemic response processes

None

Community Level Data Collection and Reporting

● Record and report services provided during every encounter with household members, including commodity management.

● Report births and deaths

● Support tracking and reporting of immunization defaulters

3.2. Selection and Recruitment

The selection of the CBHWs is a collaborative process that is primarily community-driven with guidance and support from the Local Government Health Management Team, recognized civil society groups, SPHCBs, NPHCDA, and development partners. The community mechanisms involved include the community members, Ward Development Committees (WDCs), the PHC Facility Managers, and existing traditional institutions.

Ensure that in nominating community members to serve panel members, the nominees:

● Represent diverse community perspectives,

● Have the relevant expertise;

● Understand the local culture.

● Are respected and truste;

● Are committed to the program's goals;

● Are impartial;

● Possess strong communication skills; and

● Are available for all required activities.

3.2.1 Selection Criteria

a. Auxiliary Community Health Worker

● Age range 25- 65 years (However, this is flexibility and based on local contexts. In local adaptation there is a need to emphasize maturity for effective engagement with older women and physical capability for door-to-door visits)

● Minimum of primary education, with advancement contingent on secondary education

● Able to read and write in English (or the local language)

● Preferably female, though men can be recruited where locally contextualized.

● Ever married (this included currently married, divorced or widowed)

● Respected and resident within the community.

● Culturally competent (Able to communicate effectively in the local language and understand the norms and cultural values of the community)

● Willing to serve the community for at least 2 years.

● Existing CBHWs with prior training or experience and currently in the community should be prioritised and given equal screening opportunities, if eligible

b. Junior Community Health Extension Worker (JCHEW)

● Willing to work at the community level

● Resident in the community of service

● Possess a valid certificates, including that of current registration with the National

Community Health Practitioners Board, and state of origin documentation.

● Can speak and write in English.

● Proficient in the local language and culturally competence.

● Accepted by the local community

● Documents audited and accepted by the LGA

3.2.2 Nomination and Screening Process for Auxiliary CBHW

Nominations are to be made by community members or through direct applications, where interested individuals apply directly to the community panel.

Conduct the screening of the Auxiliary CBHWs in collaboration with the focal ward PHC, the existing traditional institutions and the Ward Development Committees (WDCs), where they exist. The pre-selection meeting should be held at the ward level and should involve the National Team and/or state PHC Team, LGA Health Management Team, Officer-in-charge of the PHC facility, WDC chairman and Ward Focal Person. This meeting should be conducted to communicate the goals and objectives of the CBHW , review the selection criteria, and define the CBHWs' roles and responsibilities. Subsequently, the nominated candidates should be screened using an eligibility assessment checklist which scores the following areas:

● Age, marital status, and residency status within the community.

● Ability to read and write, both in the local language and English.

● Experience in community health-related activities.

● Formal training and certifications relevant to community health roles.

● Educational background and attainment level.

● Competencies essential for effective community health work.

● Language proficiency

See Appendix 1 for the forms for screening of the candidates.

Hold a post-selection meeting to discuss the results and select the most eligible candidates, ensuring representation from all communities in the ward.

The biodata of the candidates finally selected should be collected, verified by the candidates, and uploaded to a central database, including their passport photographs.

3.2.3 Validation of the JCHEWs

A validation exercise should be conducted to ensure the JCHEWs identified meet the eligibility criteria. They would be expected to provide copies of certification and registration as well as proof of residence within the selected ward/community.

3.3. Distribution of the CBHW

The unit for implementation of the CBHW is the ward. The number of CBHWs will depend on the size of the ward and population density. Factors that may determine the variability include:

● Population- highly populated communities should have more personnel deployed.

● Spatial distribution of households across a geographic area and the time it takes to move between them,

● The geographical terrain: hard-to-reach areas may require more personnel .

● Prevalence and incidence of health conditions of interest

However, it is recommended that the minimum number of CBHWs to be deployed per ward should be ten (10). States are at liberty to determine the proportion of JCHEW to Auxiliary Community Based Health Workers required based on empirical evidence of availability of the JCHEWs and state capacity. However, the two cadres of CBHWs are expected to work in tandem within the wards, with JCHEWs prioritised for deployment to hard-to-reach (HTR) /under-served communities.

HTR settlements are in greater need of expanded access because they are (1), cut off from other communities around them by difficult terrain caused by mountains, forests, deserts, rivers and a host of other natural barriers disrupting the movement of persons, goods and services; (2), situated in areas of insecurity, wars or communal clashes which interrupt the normal flow of health system processes; and (3), located 5km or more than 40minutes' walk from the nearest functional health facility or any constructed road, whether tarred or untarred.

3.4. Incentives and Compensations

3.4.1 Financial Compensation

CBHWs will receive compensation to cover the logistics costs, time and effort expended during service provision. As part of the formal health sector, both JCHEWs and Auxiliary CBHWs will receive a salary in line with the state salary structure and in consideration of differential remuneration based on qualification and scope of work between the two cadres.

States should also consider providing performance-based incentives (PBIs) to CBHWs and their supervisors/focal persons (at state, LGA and ward governance levels) to improve motivation and productivity.

3.4.2 Non-financial Compensation

a. Status CBHWs have an influential role in their community. This will give them a sense of satisfaction and purpose as they will make a positive impact on the lives of their community members.

b. Recognition The performance of the CBHWs will be monitored. High performing ones will benefit from awards at local or even state and national levels. They may be nominated to represent their peers at conferences and events and may be identified as champions or role models for the .

c. Career Progression

NPHCDA/SPHCBs will engage Colleges/Schools of Health Technology (SHT) and Nursing and Midwifery Colleges/Schools to explore career pathways and requirements for high- performing Auxiliary CBHWs. This will enable them to become professional healthcare workers through training and advanced education. They can become JCHEWs in the facilities and progress to being Community Health Officers (CHOs) or Nurses/midwives. JCHEWs serving in the communities can also take additional training to become CHEWs and possibly CHOs, Nurses or Midwives. Other support towards career advancement will include the following:

• Provision of scholarships for completing secondary school

• Provision of continuous supportive supervision to enhance their skills and competences enable them deliver quality services.

• Provision of various targeted formalized trainings to prepare CBHWs for continuing professional development and to enhance their skills for their next roles.

• Provision of support to LGA Health Authorities working with supervisors and WDCs to shortlist eligible candidates based on predetermined criteria for career advancement.

• Performance assessment of CBHWs to measure their skills and readiness for advancement.

4. IMPLEMENTATION

4.1 Implementation Plan

The National CBHW implementation strategy targets coverage across the 8, 856 wards of the country within a 5-year period. Table 3 provides the roadmap for expanding CBHW in the country with recommended target of universal coverage by 2028, considering availability of the JCHEWs and possible resource constraints.

The national coverage of community health worker currently stands at with a baseline of 20.0% in 2024. This will serve as the baseline. The proposal is a frontloading incremental rate of 25% in the following 2 years (2025 – 2026) and 15% increase in the remaining two years (2027 – 2028).

Table 3: Phased coverage of community-based health worker

National Population targeted by CBHW services

Roadmap for CBHW Scale-up

2024 2025 2026 2027 2028 Rural areas (%) 30.0 60.0 85.0 100.0 100.0

Urban areas (%) 10.0 30.0 55.0 70.0 100.0

Total (%) 19.3.0 43.8 68.9 83.9 100.0

Considering the differential burden of diseases and unmet needs of basic health services based on place of residence, the strategy prioritizes coverage in the early periods in rural areas. Hence, the recommendation is to have a more rapid annual increment in the rural areas, whereby 100.0% of these populations will be covered with the by 2027, while the entire urban population, and thus the total population of the country will be reached with community-based services a year later in 2028. With the current population distribution of 53.5% rural and 46.5% urban the projected scale-up coverage is shown in Table 3.

The entire national planning processes of this phased implementation framework is based on the recommendation of a blended model of the community-based health workers with a mix of 50:50 Auxiliary CBHWs and JCHEW ratio. States can, therefore, begin with an appropriate mix starting from their current point and build to an optimum of having a predominantly JCHEW led . Furthermore, as the ratio moves with time in favour of JCHEW the range of services in the comprehensive pack can be expanded to cover more curative, rehabilitative and palliative care needed in sufficient quality at the community level.

Recognizing that attainment of universal health coverage requires provision of optimal primary health care services at both facility and community levels, all stakeholders are encouraged to fast track interventions aimed at revitalizing the primary health care facilities to optimize the supply side of the health care delivery at this critical level of care.

4.1.2 Implementation Process

The CBHW implementation processes will be carried out in three phases of pre-implementation, implementation and monitoring and evaluation. The various implementation activities will be carried out at the National, State, Local Government, ward and community levels, as appropriate. Table 4 lists the various processes that inform the activities required at each phase to ensure successful . The scope of the activities and the stakeholders involved depend on the governance level where it is conducted.

Table 4: CBHW implementation process

Implementation Phase

Implementation Processes

Pre-implementation /Planning

Policy review and adaptation Stakeholder engagement and consensus building with national and subnational state actors and partners Strategy finalization Financing and resource mobilization Development/revision of guide, training materials and data tools Branding of Development of operational work plans/roadmaps at national and subnational levels Establishing a commodity and drug supply chain system Procurement of training materials and commodities, drugs and supplies Development of a communication strategy Launch

Implementation Stakeholder and community engagement/entry Establishing governance and coordination platforms Selection of the JCHEWs and ACHWs and identification of supervisors Capacity Building (Onboarding/Training)

Accreditation of the CHWs Deployment of the JCHEWs and ACHWs Mapping of houses in assigned communities, house numbering and registration and delineation of practice areas.

Service delivery Integrated supportive supervision Capacity Building (mentoring and continuous learning) Commodity and drugs supply and replenishment Performance management Operations and implementation research

Monitoring, Evaluation, Learning and Research

Routine monitoring Mid-year review Annual reviews Periodic evaluation

1. Pre-implementation phase is aimed at developing the strategy, building consensus on the implementation framework, securing buy-in of relevant stakeholders at all levels , mobilizing needed resources for implementation and setting up operational coordination platforms. The plan also includes assembling the needed resources, developing of work plans at national and subnational levels, environmental scanning and setting up objective basis for performance management through conduct of baseline assessment, development a monitoring and evaluation plan, and an accountability framework. Additionally there will be the development of and production of the guide, data tools and training materials, establishment of sustainable supply chain management system, as well as launch.

2. Implementation phase involves establishment of governance structure, procurement of commodities, printing of training materials and other documents, selection, recruitment, training and deployment of the CBHWs, service delivery, supervision, mentoring and performance management. During this operations and implementation research will be conducted to generate evidence for use to improve performance.

3. Monitoring, Evaluation, Learning and Research phase includes regular monitoring, periodic evaluation and operational research. The monitoring involves continuous and systematic collection, collation, analysis and presentation of data generated from the CBHW to track progress towards attainment of targets, identify progammatic bottlenecks for development of remedial actions to improve performance. This will be achieved through the regular analysis and use of routine data to drive decision making at all levels.

evaluation will be undertaken periodically, both internally and externally to assess the level of attainment of goals and objectives and the impact, of the on population health, as well as its relevance, scope, effectiveness, and efficiency. It is imperative to collect baseline data against which the performance of the can be evaluated.

4.2 Training

A well-coordinated training strategy is necessary to ensure the community health workers acquire the necessary competencies to perform their work effectively. The training will aid the Auxiliary CBHWs in promoting healthy practices healthcare seeking behaviour, distribution of health commodities and provision of basic curative care providing basic services, data capture and remittance. The JCHEWs training will deliver targeted and more complex prevention, diagnosis and treatment services in the communities. The robust training curriculum comprise 11 modules to be delivered using adult learning techniques, with in-class and field practical sessions is designed to focus on key things the CBHWs need to know and be able to do, so as to build the critical skills and competencies needed for effective service delivery at community level.

4.2.1.Outline of the Training Modules The training of the CBHWs comprise 12 modules. Tale 5 gives an outline of the Modules which both the ACHBW and the JCHEW will be taught, indicating the additional areas of training the JCHEWs training will cover, in line with their proposed roles and responsibilities.

Table 5: Outline of the Training Manual for the CBHWs

Module Description Additional sessions for JCHEWs

Module 1: Introduction to Primary Health Care and community health service delivery

Understanding the concept of Primary Health Care and the community-based service PHC, including the roles and responsibilities of CBHW, including and their rewards and sanctions

Module 2: Knowing your community

Understanding the community, their culture and norms, gender issues at community level, the target and how to conduct including micro-census, register household members and identify target populations.

Module 3: Interpersonal Communication and Behaviour Change Communication

The module focuses on how they can become effective counsellors and communicators, through empathetic listening, clear communication, cultural sensitivity for effective patient and family engagement, and trust-building. It also

Module Description Additional sessions for JCHEWs includes training on health promotion and conflict resolution principles.

Module 4: Conducting Home visits and referral networks

The module introduces them to steps in the conduct of how visits and how to conduct the visits, identify target groups in need of services and provide the needed services, referral protocols and documentation including. It also includes the different types of home visits – routine, emergency and follow-up visits and mobilizing household and community members for health insurance

Module 5: Care of the Pregnant woman and newborn

Participants are trained on identification of pregnant women, counselling pregnant women on health promotive and disease preventive practices during pregnancy, importance of antenatal care and institutional delivery and postnatal care, recognition of danger signs and referral and educating women and birth preparedness and complication readiness; newborn care, distribution of chlorhexidine, LLIN, misoprostol and SP and referral to the facilities for ANC, PNC and danger signs

Module 6: Care of the sick child

How to identify, assess and treat children under-five for malaria, diarrhea and pneumonia and dentify children with danger signs and referr to the PHC facilities

Module 7: Promoting Child health and Nutrition

How to provide health education and counsel for child health including immunisation and infant and young children feeding, detection of acute malnutrition and referral and counseling on appropriate feeding for children with moderate malnutrition, deworming of children and distribution of MNP and resupply of RUTF, where available)

● Provision of community-based immunisation services

● Conducting nutrition education and food demonstration sessions

Module 8: Adolescent health

Education and counseling on adolescent transitional changes, hygiene, menstrual hygiene, high behaviours during

● Screening for eligibility for contraceptives

Module Description Additional sessions for JCHEWs adolescence and reproductive, sexual and adolescent health promotion.

Needs-based referrals to PHCs.

● Dispensing condoms and oral contraceptives

Module 9: Promoting family and community health

Education on disease prevention (for malaria, HIV/AIDS and other infectious diseases) and health promotion including counselling on NCDs, WASH & nutrition, disease surveillance and community MPDSR, collection of information on birth and deaths

● Screening for hypertension, diabetes mellitus and appropriate referral

Module 10: First Aid Provision of first aid and referral as appropriate

Module 11: Care for vulnerable population

Care for the elderly, disabled and people living with mental health disorders

Module 12: Monitoring and Evaluation

Data collection and reporting, in addition to commodities management

In addition to participating in the CHW Training, the supervisors will undergo additional training of supportive supervision and mentoring. The modules they will be trained on are shown in Table 6

Table 6: Modules for the Training Manual for the Supervisors of CBHWs

Module Title Module 1 Mentoring Module 2 Supportive supervision Module 3 Community-based communication Module 4 Data management Module 5 Logistics and Supply Chain Management

4.2.2.Approaches to the Training and Retraining Process The training process will be decentralised with direct oversight by NPHCDA, SPHCBs and partners for quality control. The CBHWs will be trained by State Facilitators and health workers at the focal PHC facilities, supported by National Master Trainers to ensure quality control. The JCHEWs having been formally trained and certified, will have a 14-day retraining with support from the CHPRBN focusing on the outlined modules and additional sessions.

A cascade model of training is proposed where trainers are expected to acquire same knowledge and skills as the CBHWs

The CBHW training will be in phases, comprising an initial total of 14-day classroom and field training. These training sessions will enable them to understand their roles and provide general guidance to help them commence their work. The CBHW supervisors will sit through the CBHW training and in addition, will have a 5- day training on their roles and responsibilities with focus on mentoring and supportive supervision. Following the training, they will have a one week supervised practical before the commencement of their work

This phase of learning is followed by a 3 months structured mentoring sessions to be anchored by the CBHW supervisors aimed at reinforcing and deepening the knowledge gained during the classroom sessions. Greater attention should be given to addressing weak areas and knowledge gaps for CBHWs. The conduct of the mentoring activity will be informed by a mentoring guide specifically developed for the .

Figure 2: Training cascade for the community health workforce

The training at the national and state levels has been reduced from the 12 days to 5 days because across the country, a pool of national and state trainers have been trained, so it will be essentially refresher trainings. Where there is a need for training of fresh facilitators, the full complement of training is recommended.

The community based health workers will participate in an initial onboarding training and continuous learning exercises.

a. Onboarding Training: this will provide comprehensive foundational training on basic skills required for work in the community, as well as practical hands-on sessions to enable CBHWs to apply theoretical knowledge in real-world scenarios.

b. Continuous Learning: The formal training curriculum will be built into the continuous learning architecture to ensure the CBHWs get grounded in the required skills for their assigned roles and the relevant career pathway e.g. CHEW or Nursing pathway.

The continuous learning exercises will include;

i. On-the-job Mentoring: The CBHWs will be assigned to supervisors who provide continuous guidance, support, and feedback. This structured approach will be used to address specific challenges, refine skills, promote practical knowledge and…