Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance

The following colleagues addressed the role of Community Health Workers in promoting antenatal care in Chad: Naibei Mbaïbardoum, Ali Soumaine Baggar, Djimodoum Moyreou, Mamadjibeye Joseline, Noella Umulisa, Elana Dhuse, and Kodjo Morgah.  (Affiliation: Improving the Quality of Malaria Control Services in Chad and Cameroon program/Jhpiego, and the Provincial Health Delegation of the Logone Oriental Region, Chad). Their work entitled “Evaluation of the Contribution of Community Health Workers (CHWs) in improving Health Facility Attendance, particularly for timely ANC attendance and IPTp services, in six districts in the Provincial Health Delegation of the Logone Oriental Region in Chad” was a poster presentation at the 68th Annual meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in Chad

Malaria in pregnancy causes up to 10,000 maternal deaths each year and contributes to high rates of maternal morbidity especially in first-time mothers Malaria is a leading cause of morbidity and mortality in Chad with ~2.2 million cases of malaria occur every year in Chad. In 2017, Chad national data revealed that malaria represented 36% of outpatient consultations and 30.8% hospitalization cases. Incidence of malaria in the Logone Oriental is 122/1000.

Malaria related death rate among pregnant women decreased from 11.1% in 2013 to 4.3% in 2017. In 2017, the coverage for the first dose of intermittent preventive treatment (IPTp1) was 81%, while IPTp3 and IPTp4 were only 29% and 9%, respectively .

Community Health Strategy in Chad

Chad introduced community health interventions in 2014. Malaria community interventions consist of promoting malaria prevention and raising awareness. Jhpiego introduced the CHW reference sheet as a tool that links the community with health facilities. Jhpiego trained CHWs and their supervisors on how to use the forms in referral and counter-referral within the community.

The “Improving the Quality of Malaria Control Services in Chad and Cameroon” project, implemented by Jhpiego, has trained, equipped and supported 109 community health workers in the Logone Oriental region To improve health facility attendance by the population, starting in April 2017, 77 of the 88 trained CHWs referred suspected cases of malaria and pregnant women for ANC/IPTp services using referral and counter-referral forms.

The objective of the evaluation is to assess the contribution of the CHWs in the improvement of health facility attendance particularly for timely ANC and IPTp services, using community-based referrals.

The Evaluation/Study question was “What is the contribution of CHWs in increasing community access to preventative care treatment for malaria, especially among pregnant women and children under five?” From Feb-Mar 2019, Jhpiego conducted a records review of the following  tools:

  • Facility Reporting forms
  • Referral forms and counter-referral forms
  • Registers of ANC and other consultation visits
  • CHW supervision reports conducted by supervisors in health centers

The referrals of 72 CHWs in six districts In Logone Oriental region were reviewed for the period of Jan-Dec 2018. There were 72 CHWs.

Cases referred to health centers. In total, 1153 persons were referred by the CHW. 59.9% (691/1153) of those referrals arrived at the health centers. Pregnant women referred for ANC/IPTp services were the group who reached health centers at the highest rate, followed by children under 5.

Conclusions and Recommendations

Findings of this evaluation show that CHWs could play a significant role in improving health facility attendance, increasing ANC/IPTp compliance at health centers in six districts in the Logone Oriental region. So far, this finding has made the following possible:

  • Review the mapping of CHWs to redefine the population to be covered
  • Update all CHW tools (registers, supervision grids, report cards)
  • Make orientation maps for the pregnant woman

One of the major challenges to scaling up the use of CHWs in strengthening linkages between community-level interventions and facility services is the size and geographical scope of the population covered by CHWs. CHW registers and reference sheets are not consistently completed as required, and supervisors do not always check on this

Re-mapping of CHWs is needed following national norms to include Number of villages, households, pregnant women to be covered by CHWs. An Increase the number of CHWs is also required with a focus on recruiting female CHWs to improve communication among women that encourages ANC attendance. The health services should strengthen existing supportive supervision system from health centers to CHWs to ensure that registers and reference sheets are consistently completed, leading to better delivery of services.

This work was supported by the had Ministry of Health, ExxonMobil Foundation, Esso and Jhpiego.

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