Mise à l'échelle des agents de santé communautaire polyvalents en Haïti

Scaling Up Agents de Santé Communautaire Polyvalent in Haiti Implementing Partner: Zanmi Lasante Agreement Number: AID-OAA-A-16-00015 Agreement Duration: March 18, 2016-March 17, 2019 Reporting Period: March 18, 2016-March 17, 2017 Date Submitted: 6/16/17 Submitted by: Dr. Kenia VISSIERES & Dr. Alain CASSEUS Table of Contents SUMMARY ..................................................................................................................................................... 3 Summary of Project .................................................................................................................................. 3 Objectives ................................................................................................................................................. 3 Expected outcomes and Impact................................................................................................................ 3 PROJECT IMPLEMENTATION PROGRESS ....................................................................................................... 4 TABLE 1: PROJECT IMPLEMENTATION PROGRESS BY TECHNICAL AREA .................................................. 4 Key Achievements ..................................................................................................................................... 5 KEY RESULTS.................................................................................................................................................. 7 UPDATES ..................................................................................................................................................... 13 PMP Summary Table (Clean)................................................................................................................... 13 PMP Summary Table (Updated) ............................................................................................................. 19 NEXT STEPS ................................................................................................................................................. 28 ANNEX ......................................................................................................................................................... 29 2 SUMMARY Scaling Up Agent de Sante Communautaire Polyvalent in Haiti Summary of Project Through this project, Zanmi Lasante (ZL) is working under the Haitian Ministry of Health’s (MSPP) leadership to strengthen a unified Agent de Sante Communautaire Polyvalent (ASCP) structure in the Mirebalais commune of Haiti’s Central Plateau in order to achieve and sustain effective coverage of the essential package of health services and to serve as a model for national scale-up. This is being achieved by addressing the prioritized barriers of funding, availability of human resources, and supervision. ZL’s vision is for ASCPs to be directly linked to the health system through: 1) a systematic training and certification process; 2) a coordinated referral system; 3) a supportive supervision system; and 4) an improved information systems that will ultimately accelerate progress towards achieving and sustaining effective and scaled coverage of health and nutrition interventions in Haiti. The MSPP will thus have the appropriate tools to coordinate all implementing partners and begin harmonizing existing fragmented community health workers (CHW) programs into one unified ASCP structure, fully integrated within the larger health system and fully aligned to national policies and implementation plans. Objectives In order for these services to be scaled up and sustained, ZL is working towards three project objectives over a three year period: 1. Align ZL's network of CHWs with MSPP's new requirements and standards for ASCPs; 2. Strengthen the continuum of care by developing linkages between communities and health facilities in Mirebalais; 3. Strengthen health information systems and data management capacity in order to improve data for decision making within the ASCP network. Expected outcomes and Impact This project will work to achieve the national target ratio of 1 ASCP per 1,000 habitants. The ultimate goal and desired impact being to improve and expand health services, strengthen the health system, and gather first-hand lessons that will help influence a successful nationwide scale-up of a unified ASCP structure through this joint working relationship. In doing so, the community to facility linkage will be greatly improved and the essential package of services (Paquet essential de services, PES) will be delivered. Life of Project: 2016/2019 USAID: $ 750,000 Cost Share: $ 250,000 Leverage: $ 0 Implementing Partner: Zanmi Lasante Geographic Focus: The commune of Mirebalais in the Central Plateau department of Haiti 3 PROJECT IMPLEMENTATION PROGRESS TABLE 1: PROJECT IMPLEMENTATION PROGRESS BY TECHNICAL AREA Technical Area Activity /Activities Timeframe and Description of Progress to Date Comments (challenges, success, etc.) Child Health - Malnutrition screening in the community -Vaccination of children under 1 years -Community information and education sessions on child health -Activities were regularly undertaken each month, on a weekly basis according to planning with community health nurse coordinators -Though targets were not set for most of these activities during the first year due to the planned focus on training and outfitting of the agents, results were produced mostly from the work of the veteran ASCP Maternal Health -Family planning and PMTCT education sessions in the community -Family planning dispensed in the community to accepting women -Post natal Home visits - Activities were regularly undertaken each month, on a weekly basis according to planning with community health nurse coordinators Newborn Health -Post natal Home visits -Activities were regularly undertaken each month, with dispatching to related agents according to institutional and community births for the period WASH -WASH education and information sessions in the community - Activities were regularly undertaken each month, on a weekly basis according to planning with community health nurse coordinators Nutrition -Malnutrition screening -Referral to health - Activities were regularly undertaken 4 facilities each month, on a weekly basis according to planning with community health nurse coordinators and the nutrition nurse coordinator Malari a n/a n/a n/a TB -Screening and referral of respiratory symptomatic individuals - Activities were regularly undertaken each month, results depended on detected possible cases during home visits and rally posts -Difficulties in tracking successful arrival of referrals in the health facility prompted a movement to renew and revitalize the existing referral/counter- referral system HIV/AIDS n/a n/a n/a Health Systems Strengthening (HSS) - Formative supervision -Data quality audits -Referrals to the regional health facilities -Activities were regularly undertaken each month -Data audits took place every quarter -The referral/counter- referral system in place needs to be modified with special focus on counter-referral control Workforce Augmentation - Recruit 44 additional ASCPs for the region of Mirebalais -Train all new ASCPs and refresh current employed ASCPs -ASCPs and supervisors were recruited as planned -Training of ASCP 80% completed, one module remains to be done -3 ASCPs were lost along the way: one of the veterans died after a stroke, another was removed after discovery of fraud and the third was a new ASCP also part of the fraud -ASCP training started late in the first year which is why it could not be 100% completed as planned by the end of the project year Policy n/a n/a n/a Other (please specify) Key Achievements During the first year of the project, apart from increasing human resources by recruiting ASCPs to fill the gap in coverage within the region of Mirebalais, the other main focus is the capacity building for 5 these community workers. The MSPP curriculum for ASCP is a 5 module training of a total of about 50 business days. For better absorption of the knowledge, the 5 modules were planned to be given with at least a week or two hiatus, during which the ASCP could find time to provide services in their assigned sections of the commune. The 5 modules are titled as such (translation in parentheses): module 1 ”l’organisation des services de sante ” (The organization of health services), module 2 “Processus de Travail de l’ASCP ” (Work process of the ASCP), module 3 “ La santé aux différentes étapes de la vie“ (Health at the different stages of life), module 4 “Prévention et contrôle des maladies les plus courantes ” (Prevention and control of most common diseases), module 5 “Action des ASCP en situation de risques ” (Actions of the ASCP in crisis situations). After successful recruitment of new 44 ASCPs and 4 supervisors, the target ratio of ASCP to habitant of 1/1000 was reach and training started. Up until March 2017, 3 modules have been completed with the fourth completed in the beginning of April 2017. Before and after each module, participants’ knowledge is assessed in regards to what will be covered. Pre-test and Post-test results were analyzed using both a paired t-test method and nonparametric Wilcoxon Signed ranks test. Both analyses significantly showed an increase of knowledge and rejected the null hypothesis of the training modules being ineffective in increasing participant knowledge, with p<0.0000… in all modules. Nevertheless, module 2 presented the greatest difference in means of all, we can thus assume or posit that it was the most effective of all 3 analyzed modules. Module 4 completed in April showed results very similar in potential effectiveness to module 2, and also showing significance in knowledge gain. Certain issues arose at the beginning, which resulted in the training, the main activity for the first year, to start very late. Of those we can point out problems with disbursement of funds, late feedback when sharing documents with donors and change in scope of work. The changes also affected the budget, as the total amounts remained the same but modifications of what could be done or not were required, thus affecting our ability to execute certain desired activities. The budget was redistributed and items were either removed or marked down to the most vital and once resubmitted/approved activities could begin albeit a few months late. Beyond the access to official trainers to support eventual scale up into other communes of the country, closer involvement with the MOH needs to be felt in order for the obstacles faced during this project not be encountered each time in similar circumstances. Furthermore, as there has been great improvement in the speed at which exchanges and communication have been occurring between all partners. Keeping the pace, and even hopefully increasing it will secure the success of this endeavor. As part of expected outcomes, the experience in itself is meant to guide ZL, the MOH (MSPP) and all partners when considering the future of the ASCP model in Haiti. There are several key questions and lessons deriving from experience, such as: does the ASCP requirement criteria create barriers to entry? What is the best way to deploy ASCPs in relation to community needs? How effective will be our joint model of training, certification, and supervision? ZL is in a position to immediately apply project lessons to improve the training process for the ASCP workforce moving forward, particularly in the Central Plateau and Artibonite departments, where ASCPs are present. Training is proving to be effective so far in terms of immediate knowledge gain. Further proof will stem from observing the provision of services and the results of the work done by the newly deployed ASCPs during the second year of the project. 6 KEY RESULTS GOAL: Under MSPP’s leadership strengthen a unified ASCP structure in Mirebalais to achieve and sustain effective coverage of the essential package of health services and to serve as model for national scale-up Expected Results Code Performance Indicator Unit of Measure Method of Data Collection Data frequency Delivera- ble Data Baseli ne value Target Result Source FY FY FY 2015 2016 2016 Project Objective 1: Align ZL's network of CHWs with MSPP's new requirements and standards MSPP’s target ratio of 1 ASCP per 1,000 people in Mireba- lais achieved 1.1 1.1.1 Number of ASCPs recruited Number Registration One-time N/A HUM employe es contract 60 100 100 1.1.2 Number of ASCPs trained and certified Number Registration Monthly Training and Certifica- tion reports CNF Records 0 100 0 Atten- dance sheets 1.1.3 Ratio of ASCPs to population Ratio Numerator : Number of ASCPs serving Mirebalais One-time N/A MSPP/Z L records _ 1 per 1,000 people 1 per 1,000 people 7 Denominator : Population of Mirebalais Project Objective 2 : Strengthen continuum of care by developing linkages between communities and health facilities in Mirebalais Increased ratio of ASCP Supervi- sors to ASCPs 2.1 2.1.1 Number of ASCP Supervisors recruited Number Registration One-time N/A ZL employe es contract 6 10 10 2.1.2 Number of ASCP Supervisors trained Number Training Records One-time Training report CNF Records 0 10 10 Atten- dance sheets 2.1.3 Number of ASCPs assigned to ASCP Supervisor Number Registration One-time N/A Map- ping of the ZL commu- nity staff 57 100 100 2.1.4 Ratio of ASCP Supervisors to ASCPs Ratio Numerator : Number of ASCP supervisors One-time N/A Map- ping of the ZL commu- nity staff _ 1 Supervisor to 10 ASCPs 1 Supervis or to 10 ASCPs 8 Denominator : Number of ASCPs ASCPs supervi- sed at both the commu- nity and facility level 2.2 2.2.1 Number of monthly supervision meetings conducted Number Registration Monthly Supervisio n report Monthly supervi- sion reports 0 0 2 Improved referral and counter- referral processes 2.3 2.3.1 Number of ASCP home visits conducted per month per ASCP Number ASCP report Monthly N/A ZL Home visits registers 0 0 39407 2.3.2 Number of rally posts organized in the community Number ASCP report Monthly Rally post ZL rally post registers 0 0 2078 Number of Respiratory Symptomatic referred to the facility Number ASCP report Monthly New RS identified RS registers 0 0 6 Number of women receiving family planning during community activities Number ASCP report Monthly Women on FP FP registers 0 0 3247 Number of child bearing women receiving education on family planning Number ASCP report Monthly Women on FP IEC registers 0 0 0 9 % of referrals from ASCP received at the hospital Number Hospital registers Monthly New cases received for follow up ASCP report 0 0 0 Hospital registers Number of children screened for malnutrition and referred during community activities (rally post, home visits, etc.) Number ASCP report Monthly New cases referred for follow up at the clinics ASCP registers 0 0 256 % of referrals treated and enrolled in a long- term treatment (Nutrition, TB, VIH) % Num: referrals treated and enrolled in a LT treatment Monthly NA ASCP report 0 100% 0 Deno: Number of referrals received at the hospital Hospital registers % of counter referrals received by the ASCP % ASCP report Monthly NA ASCP report 0 100% 0 Hospital registers Hospital registers 2.3.3 Number of <1 year old fully vaccinated Number ASCP report Monthly Vaccinatio n ZL immuni- zation registers 0 2524 1672 10 2.3.4 Number of vaccination information sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 2059 2.3.5 Number of PMTCT information sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 252 2.3.6 Number of pediatric education sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 671 2.3.7 Number of WASH (Water, Sanitation, and Hygiene) education sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 1053 Project Objective 3 : Strengthen HIS and data management capacity Increase consisten -cy of data collec- tion 3.1 3.1.1 Number of ASCPs trained in data collection Number CNF records One-time N/A Atten- dance sheet 0 100 60 3.1.2 % of tools adequately and completely filled out % ASCP tools verification Monthly NA Supervi- sion reports - 100% 43% Improve data quality and analysis 3.2 3.2.1 Number of ASCP Supervisors trained on data quality and analysis Number CNF records Quarterly N/A Atten- dance sheet 0 10 6 11 Number of formative supervision conducted for ASCP supervisors Number Note One-time NA Supervi- sion reports 0 0 0 3.2.2 Number of M&E quarterly meetings to review the project performance Number Notes and support documents Monthly NA Meeting notes 0 2 1 3.2.3 Number of data quality audits conducted Number MEQ Report N/A Data Quality Audit reports 0 1 2 12 UPDATES PMP Summary Table (Clean) GOAL: Under MSPP’s leadership strengthen a unified ASCP structure in Mirebalais to achieve and sustain effective coverage of the essential package of health services and to serve as model for national scale-up Expected Results Code Performance Indicator Unit of Measu- re Method of Data Collection Data frequency Delivera- ble Data Baseline value Target Result Target Tar- get Source FY FY FY FY FY 2015 2016 2016 2017 2018 Project Objective 1: Align ZL's network of CHWs with MSPP's new requirements and standards MSPP’s target ratio of 1 ASCP per 1,000 people in Mirebalais achieved 1.1 1.1.1 Number of ASCPs recruited Num- ber Registration One-time N/A HUM employees contract 57 100 _ _ 1.1.2 Number of ASCPs trained and certified Num- ber Registration Monthly Training and Certifica tion reports CNF Records Attendanc e sheets 0 100 _ _ 13 1.1.3 Ratio of ASCPs to population Ratio Numerator : Number of ASCPs serving Mirebalais Denominator : Population of Mirebalais One-time N/A MSPP/ZL records _ 1 ASCP per 1,000 people _ _ _ Project Objective 2 : Strengthen continuum of care by developing linkages between communities and health facilities in Mirebalais Increased ratio of ASCP Supervisors to ASCPs 2.1 2.1.1 Number of ASCP Supervisors recruited Num- ber Registration One-time N/A ZL employees contract 5 10 _ _ 2.1.2 Number of ASCP Supervisors trained Num- ber Training Records One-time Training report CNF Records Attendanc e sheets 0 10 _ _ 2.1.3 Number of ASCPs assigned to ASCP Supervisor Num- ber Registration One-time N/A Mapping of the ZL communit y staff 57 100 _ _ 2.1.4 Ratio of ASCP Supervisors to ASCPs Ratio Numerator : Number of ASCP supervisors Denominator : One-time N/A Mapping of the ZL communit y staff _ 1 Supervi sor to 10 _ _ _ 14 Number of ASCPs ASCPs ASCPs supervised at both the community and facility level 2.2 2.2.1 Number of monthly supervision meetings conducted Num- ber Registration Monthly Supervis ion report Monthly supervisio n reports 0 0 12 12 Improved referral and counter-referral processes 2.3 2.3.1 Number of ASCP home visits conducted per month per ASCP Num- ber ASCP report Monthly N/A ZL Home visits registers 0 0 12,000 12,0 00 2.3.2 Number of rally posts organized in the community Num- ber ASCP report Monthly Rally post ZL rally post registers 0 0 4,800 4,80 0 Number of Respiratory Symptomatic referred to the facility Num- ber ASCP report Monthly New RS identifie d RS registers 0 0 1764 TBD Number of women receiving family planning Num- ber ASCP report Monthly Women on FP FP registers 0 0 15 during community activities Number of child bearing women receiving education on family planning Num- ber ASCP report Monthly Women on FP IEC registers 0 0 25,574 TB D % of referrals from ASCP received at the hospital Num- ber Hospital registers Monthly New cases received for follow up ASCP report Hospital registers 0 0 100% TB D Number of children screened for malnutrition and referred during community activities (rally post, home visits, etc.) Num- ber ASCP report Monthly New cases referred for follow up at the clinics ASCP registers 0 0 1729 TBD 16 % of referrals treated and enrolled in a long-term treatment (Nutrition, TB, VIH) % Num: referrals treated and enrolled in a LT treatment Deno: Number of referrals received at the hospital Monthly NA ASCP report Hospital registers 0 100% 100% 100 % % of counter referrals received by the ASCP % ASCP report Hospital registers Monthly NA ASCP report Hospital registers 0 100% 100% 100 % 2.3.3 Number of <1 year olds fully vaccinated Num- ber ASCP report Monthly Vaccina- tion ZL immunizat ion registers 0 2524 TBD TBD 2.3.4 Number of vaccination information sessions Num- ber ASCP report Monthly Educa- tion ZL IEC registers 0 1200 TBD TBD 2.3.5 Number of PMTCT information sessions Num- ber ASCP report Monthly Educa- tion ZL IEC registers 0 1200 TBD TBD 2.3.6 Number of pediatric Num- ber ASCP report Monthly Educa- tion ZL IEC registers 0 1200 TBD TBD 17 education sessions 2.3.7 Number of WASH (Water, Sanitation, and Hygiene) education sessions Num- ber ASCP report Monthly Educa- tion ZL IEC registers 0 1200 TBD TBD Project Objective 3 : Strengthen HIS and data management capacity Increase consistency of data collection 3.1 3.1.1 Number of ASCPs trained in data collection Num- ber CNF records One-time N/A Attendan- ce sheet 0 100 _ _ 3.1.2 % of tools adequately and completely filled out % ASCP tools verification Monthly NA Supervi- sion reports 100% 100% 100 % Improve data quality and analysis 3.2 3.2.1 Number of ASCP Supervisors trained on data quality and analysis Num- ber CNF records Quarterly N/A Attendan- ce sheet 0 10 _ _ 18 Number of formative supervision conducted for ASCP supervisors Num- ber Note One-time NA Supervi- sion reports 0 0 1200 120 0 3.2.2 Number of M&E quarterly meetings to review the project performance Num- ber Notes and support documents Monthly NA Meeting notes 0 2 4 4 3.2.3 Number of data quality audits conducted Num- ber MEQ Report N/A Data Quality Audit reports 0 1 4 4 PMP Summary Table (Updated) GOAL: Under MSPP’s leadership strengthen a unified ASCP structure in Mirebalais to achieve and sustain effective coverage of the essential package of health services and to serve as model for national scale-up 19 Expected Results Code Performance Indicator Unit of Measure Method of Data Collection Data frequency Deliverable Data Baseline value Target Result Target Tar- get Source FY FY FY FY FY 2015 2016 2016 2017 2018 Project Objective 1: Align ZL's network of CHWs with MSPP's new requirements and standards MSPP’s target ratio of 1 ASCP per 1,000 people in Mirebalais achieved 1.1 1.1.1 Number of ASCPs recruited Number Registration One- time N/A HUM employee s contract 57 100 _ _ 1.1.2 Number of ASCPs trained and certified Number Registration Monthly Training and Certifica- tion reports CNF Records Attendan ce sheets 0 100 _ _ 1.1.3 Ratio of ASCPs to population Ratio Numerator : Number of ASCPs serving Mirebalais Denomina- tor : Population of Mirebalais One- time N/A MSPP/ZL records _ 1 ASCP per 1,000 people _ _ _ Project Objective 2 : Strengthen continuum of care by developing linkages between communities and health facilities in Mirebalais 20 Increased ratio of ASCP Supervisors to ASCPs 2.1 2.1.1 Number of ASCP Supervisors recruited Number Registration One- time N/A ZL employee s contract 5 10 _ _ 2.1.2 Number of ASCP Supervisors trained Number Training Records One- time Training report CNF Records Attendan ce sheets 0 10 _ _ 2.1.3 Number of ASCPs assigned to ASCP Supervisor Number Registration One- time N/A Mapping of the ZL communi ty staff 57 100 _ _ 2.1.4 Ratio of ASCP Supervisors to ASCPs Ratio Numerator : Number of ASCP supervisors Denominato r : Number of ASCPs One- time N/A Mapping of the ZL communi ty staff _ 1 Supervi sor to 10 ASCPs _ _ _ ASCPs supervised at both the community and facility level 2.2 2.2.1 Number of monthly supervision Number Registration Monthly Supervisio n report Monthly supervisio n reports 0 0 12 12 21 meetings conducted Improved referral and counter-referral processes 2.3 2.3.1 Number of ASCP home visits conducted per month per ASCP Number ASCP report Monthly N/A ZL Home visits registers 0 0 120,00 0 120, 000 2.3.2 Number of rally posts organized in the community Number ASCP report Monthly Rally post ZL rally post registers 0 0 4,800 4,80 0 Number of Respiratory Symptomati c referred to the facility Number ASCP report Monthly New RS identified RS registers 0 0 1764 TBD Number of women receiving family planning during Num- ber ASCP report Monthly Women on FP FP registers 0 0 - - 22 community activities Number of child bearing women receiving education on family planning Num- ber ASCP report Monthly Women on FP IEC registers 0 0 25,574 TBD % of referrals from ASCP received at the hospital Number Hospital registers Monthly New cases received for follow up ASCP report Hospital registers 0 0 100% TBD Number of children screened for malnutritio n and referred during community activities (rally post, home visits, Number ASCP report Monthly New cases referred for follow up at the clinics ASCP registers 0 0 1729 TBD 23 etc.) % of referrals treated and enrolled in a long-term treatment (Nutrition, TB, VIH) % Num: referrals treated and enrolled in a LT treatment Deno: Number of referrals received at the hospital Monthly NA ASCP report Hospital registers 0 100% 100% 100 % % of counter referrals received by the ASCP % ASCP report Hospital registers Monthly NA ASCP report Hospital registers 0 100% 100% 100 % 2.3.3 Number of <1 year olds fully vaccinated Number ASCP report Monthly Vaccinatio n ZL immuniza tion registers 0 2524 2524 TBD 2.3.4 Number of vaccination information Number ASCP report Monthly Education ZL IEC registers 0 1200 2000 TBD 24 sessions 2.3.5 Number of PMTCT information sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 1200 TBD 2.3.6 Number of pediatric education sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 1200 TBD 2.3.7 Number of WASH (Water, Sanitation, and Hygiene) education sessions Number ASCP report Monthly Education ZL IEC registers 0 1200 1200 TBD Project Objective 3 : Strengthen HIS and data management capacity Increase consistency of data collection 3.1 3.1.1 Number of ASCPs trained in data Number CNF records One- time N/A Attendan ce sheet 0 100 _ _ 25 collection 3.1.2 % of tools adequately and completely filled out % ASCP tools verification Monthly NA Supervisi on reports 100% 100% 100 % Improve data quality and analysis 3.2 3.2.1 Number of ASCP Supervisors trained on data quality and analysis Number CNF records Quarterl y N/A Attendan ce sheet 0 10 _ _ Number of formative supervision conducted for ASCP supervisors Number Note One- time NA Supervisi on reports 0 0 1200 120 0 3.2.2 Number of M&E quarterly meetings to review the project Number Notes and support documents Monthly NA Meeting notes 0 2 4 4 26 performanc e 3.2.3 Number of data quality audits conducted Number MEQ Report N/A Data Quality Audit reports 0 1 4 4 27 NEXT STEPS Although one of the main activities during the first year, the training, has been delayed in its completion (80% completed), the project overall is on track. Many activities done by the ASCP themselves were completed such as vaccination campaigns, weekly education sessions on WASH and maternal/child health, home visits. The final module will be given, thus ensuring full capacity of the staff to render required services in an optimal manner. On the operational level, strategies are being discussed by the different administrative teams to streamline processes in order to be able to match the needs of the technical team while adhering to policies. While the human resources barrier remains mainly a financial one, the training curriculum and trainers of the MSPP have provided satisfying capacity building for the ASPC of Mirebalais. As a result, ZL slowly started to plan and implement the training modules in certain other regions where it has ASCP (Cange, Thomonde, Saint Marc …), using other the lessons learned from the Mirebalais experience up to this point. 28 ANNEX Figure 1. Visual Depiction of the Health System 29