Research Report on Community Views on Community Health Workers

E.D. Masiyiwa, M Hatendi Womens Action Group

For TARSC - Community Working Group on Health November 2000

With supported from NOVIB TARSC/CWGH MONOGRAPH 22/2000 Table of Contents

Content Page

Introduction 1

The Respondents 1

CHW Roles 2

CHW Activities 4

Workloads 5

Election of the CHW 5

Relations with the Health Team 7

Payments 9

Community Input 10

Conclusion 11

Recommendations 12

Research Report on Community Views on Community Health Workers

Introduction

The Ministry of Health and Child Welfare is in the process of re-introducing the Village Health Worker. At present there is the Village Community Worker (VCW) who is working at the grassroots level. The VCW reports to a number of ministries which makes it difficult for her/him to concentrate on health issues only. The VHW programme was introduced soon after independence but was phased out upon the introduction of the VCW programme. The VCW programme came under the Ministry of National Affairs and Employment Creation.

The re-introduction of the VHW comes as a response to the Health Review Commission Report (1999). There are, however, some issues which need to be looked into, such as, the selection criteria, roles and functions and how much the Village Health Workers should be paid. Hence, the need to conduct research on these issues. The research was commissioned by CWGH through the Information Committee to establish communities’ views on Community Health Workers. The research was conducted in two geographical areas of Mashonaland Central Province and the Midland Province. One ward from each province was selected namely Mudzengerere ward in Mt. Darwin District Mashonaland Central and Tongogara Ward in in the . Data were collected over a period of three days in November 2000 in each ward through focus group discussions with various community groups. The research was funded by NOVIB. The questions asked to the focus groups are attached at the end of this report. The groups were men, women and youths. Interviews were held with councillors, nurses and one chief.

Aim: To establish communities’ views on Community Health Workers with regards to the functions/roles, selection criteria, remuneration, relations with health teams and the community input.

The Respondents: From the Mount Darwin, Mudzengerere Ward, three focus groups were held. One group comprised of 32 youths. The age range was 16-30 years. There were 10 girls and 22 boys in the group. The second focus group had a total of 28 women. Most of the women were in the childbearing age. The third focus group comprised of men with the total number of men being 21. Among the men were 2 VCW’s, headmen and a councillor. An interview was also held with the nurse at Dotito Clinic. The clinic is situated in a different ward from Mudzengerere but it is the one where the community from Mudzengerere ward goes.

In Shurugwi District in Tongogara Ward 12 focus groups discussions were also conducted. The researchers collected data on Community Health Workers from the Chief, the Council Chairperson, the nurse at the health center (Tongogara Clinic), groups of women, men and the youths. The total numbers of youths were 15 boys only, women were 20 with a mix between those of childbearing age and elderly women, and the men were 23.

Research Findings:

CHW Roles

In response to the question regarding what the roles of the CHW should entail, the youth from Mount Darwin outlined the functions of the CHW as: • giving advice on health issues an example given was HIV/AIDS education • ensure that communities have safe water and good sanitation • promoting hygiene in the homes

The women’s group mentioned the following: • Prevention activities—examples given on these were health education on the need to drink safe water. • Treating minor ailments and diseases such as malaria. • Health education on hygiene and prevention of diseases • Encouraging mothers to take their children to the baby clinic.

When asked what role the CHW should undertake, the men saw the role of the CHW as that of assessing health conditions, diseases and other relating minor ailments. They also felt that the CHW should be responsible for prevention of diseases by educating communities to construct toilets. The CHW should also keep a record of the patients in the area. The group also said the CHW should report any health problems they come across to the health workers.

The nurse welcomed the idea of reintroducing the Village Health Worker. She outlined the expected role of the VHW as follows: • Giving Health education • Doing community home based care • Solving health problems in the community

The Chief and Council Chairperson from Shurugwi district felt that the CHW should operate at the village level, representing one village. His/her functions should include: • Treating minor ailments and refer complicated cases, therefore should be able to administer drugs such as malaria drugs. • Assessing patients and the general surroundings. • Assist in HBC activities and advise accordingly.

The youths from Shurugwi District cited the following roles and functions of the CHW: • Health education on hygiene. • Education on child sexual abuse which they expressed is on the increase in schools and the community. • Advise youths on sexuality issues and reproductive health, example given was abstaining from premarital sex. • Ensure safe water supply and good sanitation. • The youth expressed that the CHW should not keep any drugs except contraceptives because there are many unwanted pregnancies. • They also suggested that the CHW should work every day so as to cater for emergencies.

The women’s group cited the following roles and functions: • Ensure that water and sanitation programmes are initiated. • Assist in HBC activities and give advice accordingly. • Follow up discharged patients with chronic illnesses. • Treat minor ailments such as headaches, malaria, and dress wounds.

The men cited the following roles and functions of the CHW. • Promotion of health • Prevention of communicable diseases • Ensure the implementation of water and sanitation programmes. • Treat minor ailments and dress wounds. • Provide first aid treatment. • Home visits for the ill patients. • Assess the health situation in the village.

The nurse from Tongogara Clinic expressed that the CHW should: • Give health education • Assist in home based care • Treat minor ailments including malaria.

When the youth of Mt Darwin District were asked about the role of the current VCW’s, CBD’s and other community workers in relation to the CHW’s, the group was not clear. However, they said each one would know what their duties are and they should do their duties.

On the other hand, when the women were asked what the role of the current VCW’s, CBD’s and other community workers should be in relation to the CHW, the group mentioned that VCW’s are not working well because their allowance is very low. This was demotivating. The group, however, felt the community workers were going to contribute to the development of communities if their roles are well defined.

When the men were asked about the role of the current VCW’s, CBD’s in relation to the CHW, the group said these community workers should be able to work together.

The Chief and the Council Chairperson from Shurugwi District said that the role of the current VCW’s, CBD’s and other community-based workers in relation to the CHW should be supportive and compliment the CHW’s work. The respondents, however, expressed that there is need to prepare the VCW’s and CBD’s so that they get to understand the role and function of the CHW. This will assist in the three cadres working together well and ensure lack of conflict.

CHW Activities

On whether the CHW should carry out home based care or not, the youths in Mt Darwin said the CHW should not carry out home based care. The CHW instead, should give advice on the care of a patient at home. The family members should undertake the actual care.

On prevention and promotion activities to be done by the CHW, the group agreed that the CHW should give health education to communities

On who should carry out HBC, the women said that the CHW should not carry out home based care. Instead, the CHW should give advice on the care of patients at home. They, however, said it is the duty of the CHW to visit all the patients on home based care to assess their conditions and be able to report to the health centre.

On promotion and prevention activities, the group felt that the CHW should visit homes and give advice on good hygiene.

With regards to HBC, the men said the CHW should not carry out home-based care. They said it was the duty of the relatives to care for their sick. They, however, agreed that the CHW should visit those who are on home based care and advise the relatives on the care of the sick.

With regards to possible prevention and promotion activities, the group mentioned health education as the main activity. They also mentioned that the CHW should advise communities accordingly

The nurse felt that the CHW should carry out home-based care.

On prevention and promotion activities to be carried out by the CHW, the nurse said the CHW should carry out health education on common diseases in the area. The CHW should also motivate communities and advise communities on general hygiene.

The Shurugwi Chief and Council Chairperson did not think that the CHW should carry out home based care (HBC), but should provide information and advice on HBC as well as assess HBC patients’ conditions and refer.

The suggested preventive and promotion activities to be done by the CHW were as follows: • Health education • Encourage preventive health e.g. water and sanitation programmes • Report those who resist the offered advice to the Chiefs and Headmen so that the problem can be addressed, and become cooperative.

When asked whether the CHW should carry out HBC, the youths of Shurugwi District had no comment on HBC.

The preventive and promotion activities that the CHW should undertake were identified as health education and supervision of homes and to offer advise accordingly.

When asked if they think the CHW should carry out HBC or not, Shurugwi women felt that she/he should not. The family members should take care of their ill patient while the CHW supervises, gives advice and information on HBC. He/she should assist by assessing the patient’s condition and refer when necessary.

The preventive and promotion activities identified by the women were health education on prevention of diseases and promotion of health as well as education on HBC.

The men also said that the CHW should not undertake HBC, but suggested that the CHW should just supervise and offer advice.

The preventive and promotion activities cited by the nurse at Tongogara Clinic were health education on prevention of common diseases, general hygiene, and motivate the communities in water and sanitation programmes.

Workloads:

The youths of Mt Darwin were divided on how many days per week the CHW should work. Some felt that 2 days were enough whilst others proposed that the CHW works 3 days per week. They however agreed that the CHW should avail herself/himself for emergencies.

When asked whether the CHW should work on a regular basis the women in Mt Darwin agreed that the CHW should work 2 days a week. They gave the reason that the CHW also had to look after her family as such the job should not be a full time job.

The Chief and the Council Chairperson of Shurugwi District proposed that the CHW should work 3 days per week.

Women of Shurugwi District suggested that the CHW should work 3 days, as she will be doing other roles for her family.

The men, on the other hand, thought the CHW should work 5 days a week.

The nurse felt that the CHW should work 3 days per week and that he/she should supervise HBC activities.

Election of the CHW:

On who should elect the CHW, the youths of Mt Darwin agreed that community members should elect this cadre. They also expressed that they would also like to participate in the selection as youths.

The group gave the following as the criteria for selection of a CHW:

• ‘O’ Level. The candidate should not necessarily have passed ‘O’ Level but should have reached ‘O’ Level so that they can read and write reports. • Someone who is approachable. • Should be a young person • Age—around 30 years with children.

The women also agreed that communities should select the CHW and the Ministry does the interviews on the selected few. The selection criteria was outlined as follows:

• A person with good personality • Literate—grade 7 and above. Actually the group emphasized that the person should be able to read and write. • Patient and caring. • Should be a female—the group argued that women are generally caring and are always available. The women said men are sometimes difficult to get because they might be away from home drinking beer. It was however mentioned that at times women are sometimes denied permission to work. This could present problems for some women who want to be selected for this job.

When asked about the election of and the selection criteria for the CHW, the men also agreed that the community should elect the CHW. They outlined the criteria for selection as follows:

• Someone who has gone up to the ‘O’ Level • Someone who has good behaviour. • Someone who can communicate well with others. • Someone who is not corrupt • Can be either male or female

There was however some arguments on whether the CHW should be male or female. Some members of the group felt it was not proper for a woman to go to work, leaving the husband behind. They were therefore arguing that men should take up the CHW positions. The group was, however, able to reach a consensus after a discussion on gender equality.

The nurse also said the community and the nurse at the clinic should be involved in choosing the community health worker. Regarding the selection criteria, the nurse said that the CHW should be someone who can read and write, the CHW should also be a hard worker.

On who should elect the CHW, the Shurugwi Chief and the Council Chairperson strongly felt that the community should choose the CHW.

When asked who should qualify to be a CHW, the Chief and Council Chairperson suggested that the cadre should be able to read and write and has reached ‘O’ Level passed or not. They also suggested that the CHW should be a female because women have been found to be caring and hardworking. The other reason they gave was that men would spend money in beer whereas women will use the money on family needs. Women use money wisely. The respondents would like a mature married woman with children and in her 30’s to be chosen as the CHW.

The youths from Shurugwi District responded that the community including the youths should elect the CHW. The qualities of the CHW cited included:

• A person with good behaviour • Educated from Form II upwards • Be 30 years and above. • The CHW should be a female and the reason was that women are generally loving, caring and patient. The group expressed that men generally have no time for such work and always in beer halls drinking beer.

Women in Shurugwi felt that the community should do the election since they know their people better. On who should qualify to be a CHW, women cited a person with the following characteristics: • A person who is patient, loving, tolerant, good communicator, receptive, feels for others with good behaviour. • The education level should be from Grade 7 to ‘O’ Level. • Age range being 30-40 years and should be able to read and write in English. • The person can either be male or female and married. • The CHW has to be a person who is always available, with his/her homestead in the village.

The Shurugwi men’s responses were that the community in the village should elect the CHW. The following were qualities expected of a potential CHW: • The person should be smart with good personal hygiene, should have love for people and value life and not be cruel. • He/she should have reached ‘O’ Level even not passed but can read and write English. • The age range should be 25-40 years and either male or female.

The Tongogara clinic nurse felt that the community should elect the CHW who can read and write reports very well, who has done a Red Cross course and is committed to do the work. The CHW can be either male or female.

Relations with Health Team:

On who the CHW should work with in the health team, the group of youths from Mount Darwin felt that the CHW should work with the environmental health technician since he is the one who works directly with the community. They however said that there is need also for the CHW to work with the nurse at the clinic, since there is need to get first aid supplies from the clinic.

When asked whom the CHW should report to, the group gave the following response: • In the community—The group felt that in the community the CHW should report to the headmen. • In terms of health services—The CHW should report to the nurse and the environmental health technician. • In terms of local government—the council.

With regards to whom the CHW should work with in the health team, the group of Mt Darwin women felt the CHW should work closely with the EHT’s. Their reason for this was that the EHT is the person who goes into the communities, as such the EHT is accessible.

When asked the question about who the CHW should report to, the group agreed that in terms of the community, the CHW should report to both communities and headman. In terms of the health services, the CHW should report to the nurse at the local clinic. The group felt that there was no need for the CHW to report to the councillor since the councillor is responsible for several villages.

Men in Mt Darwin felt that the CHW should work closely with women mainly but should be able to work with the community at large.

The men also responded that the CHW should report to the community, the nurse at the clinic and the councillor.

The nurse felt that the CHW should work closely with the nurse at the clinic, i.e. preparing the report on common disease in the area.

In terms of the community, the nurse felt that the CHW should report to the headmen and to the nurse for health services. The nurse did not see the need for the CHW to report to local government

In Shurugwi, the Chief and Council Chairperson identified the nurse at the nearest health centre to be the person who should work with the CHW.

When asked whom should the CHW report in terms of the community, health services and local government, the respondents identified the headmen in the community, nurse at the nearest health centre and the councillor.

When asked who should work with the CHW in the health team and to who they should report to in terms of the community, health services and local government, the youths of Shurugwi District indicated that the CHW should work with the nurse at the health centre and report to the nurse at the health centre and the councilor. They couldn’t identify a cadre/person to whom the CHW can report in the community.

When Shurugwi women were asked whom the CHW should work with in the health team. Women identified the nurse at the nearest health centre as the closest person to work with the CHW.

When asked to whom the CHW should report to in terms of the community, health services and local government, the women cited the headmen, nurses at the nearest clinic and the councilor.

The men from Shurugwi were also asked whom the CHW should work with in the health team. The response was the nurse at the local clinic. Another question was asked on whom the CHW should report to in terms of the community, health services and local government. The men cited the headmen and the nurse at the clinic. They strongly felt that the CHW should not report to the councillor, as the process is cumbersome and that councilors do not respond quickly to peoples needs.

In response to who should the CHW work with in the health team and who to report to, the nurse indicated that the CHW should work with the nurse at the nearest health clinic and the Environmental Health Technician. She also indicated that the CHW should report to the headman and nurse at the nearest health centre and the councilor.

Payments:

When asked who should pay the CHW, the group of youths from Mount Darwin said the central government should pay the CHW since he/she will be carrying a national duty. The group also felt that the CHW should be paid $5000,00 a month.

With regards to who should pay the CHW and how much, the Mt Darwin women identified central government as the authority responsible for paying the CHW. They said the CHW’s should be paid $5000,00 a month.

Within the group of men from Mt Darwin, there was agreement that the central government should pay the CHW. A salary of $4000,00 per month was agreed on.

On who should pay the CHW, the response was the central government. The nurse recommended that the worker should be paid the minimum wage $1000,00 per month.

The Chief and Council Chairperson from Shurugwi district suggested the Central Government through the MOH&CW should pay the CHW, a minimum of $1000,00 per month.

The Shurugwi district youths were asked who should pay the CHW and how much. They identified the central government and the local government and be paid $4000,00- $6000,00 a month.

Women from Shurugwi district were asked who should pay the CHW and how much they should be paid. The central government through MOH&CW was identified to pay the CHW, and their salary should be $2000,00 per month plus a bicycle when operating at VIDCO level. But when he/she is operating at village level then there is no need for a bicycle.

When asked who should pay the CHW, the men’s response was central government through MOH&CW. The salary suggested as $2000,00-$4000,00 per month.

When asked who should pay the CHW and how much, the nurse recommended the government (MOH&CW) but expressed that the salary/allowance should not be disclosed until the cadre is employed. This, she said, should be done so that only committed people will be employed

Community Input:

The group of youths from Mt Darwin district ward were also asked what input should the community make to the work of the CHW. They said that it was very important to support the CHW in all the activities. An example given was if there was need for construction of Blair toilets, everyone should make sure that they construct toilets at their homes.

When asked about possible input from the community, the Mt Darwin women felt that as communities they should give the CHW support. They also said that they should participate in the health programmes that are initiated by the CHW.

The men from Mt Darwin felt that the community should support the CHW. An example is giving their human resource abilities where needed.

The nurse also felt that the community should support the CHW in all the programmes initiated in the village. An example is keeping their homes clean.

With regards to what input the community should make to the work of the CHW, the Shurugwi Chief and the Council Chairperson felt that the community should give support and cooperate with the CHW on issues that need combined effort, e.g. water and sanitation programme and general hygiene. The community should assist by encouraging those resistant to advice to be cooperative.

The group of youths from Shurugwi District were asked what input the community should make to the work of the CHW. Their responses were: • A resource such as manpower when labour is required. • Support and cooperation

The women from Shurugwi district were also asked what input the community should make to the work of the CHW. Their response was to give advice, direction and support.

In terms of what input the community should make and expected changes when the CHW’s were introduced, the Shurugwi nurse’s response was that the community should support the CHW and cooperate with the cadre. The changes expected included reduction in the numbers of patients coming to the health centre with minor ailments and improvements of the health situation in the villages.

On the changes expected if CHW’s were introduced, the group of youths from Mount Darwin felt that there would be an improvement in home-based care activities.

When asked about the changes they expected if CHW’s were reintroduced, the women from Mount Darwin expected to see a decrease in the incidences of diseases such as malaria, cholera and diarrhoea

The men expected that if the CHW is reintroduced the CHW will be effective in health programmes since he/she will be focusing on health only.

There was definitely going to be a change if the CHW was reintroduced. The nurse felt that the VCW who is present at the moment is not doing enough as far as health is concerned because she/he reports to more than one ministry.

The Shurugwi district Chief and Council Chairperson outlined the following expected changes when CHW’s are introduced: • The CHW will work for the people whole heartedly because he/she will have been chosen by the people and belongs to the people. • The community will be free to approach the cadre. • The cadre identifies with the people and their problems therefore it becomes easy and quicker to address them

When asked what changes in health they would expect with the reintroduction of the CHW, the youths of Shurugwi District said they would expect a reduction in the incidence of communicable diseases.

The women also cited the following changes: • Communication with other health workers will be faster. • Health problems will be addressed in time. • There will be improvement on villages health, e.g. cleanliness and reduction in incidence of communicable diseases • Supervision of the CHW will improve.

The men cited the following changes: • Improvement on people’s health and community surroundings. • Construction of toilets and protected wells. • Provision of chlorine for wells. • Supervision of ill patients in the home.

Conclusion:

From the focus group discussions, whose results have been presented, there was an agreement that there is a need to reintroduce CHW’s at the village level. Communities felt that the VCW who is there at the present reports to many ministries and this results in him/her not giving enough time for health activities.

Conclusions made include that communities view the role of the CHW as that of carrying out promotion and preventive health activities such as HIE, treating minor ailments, ensuring the implementation of water and sanitation programmes and supervising care of patients at home and giving the necessary advice. All the respondents strongly felt that the CHW should not do home based care activities but just supervise and offer advice. Communities also view the job of the CHW as a part time job where the cadre should work 3 days a week and always be available when needed.

From the data collected it is apparent that the community should elect the CHW. The suitable candidate should be able to read and write having gone through secondary education, mature, live in the village, someone who is patient and able to work with the people. The candidate should be married, between 25-40 years old, and it can be either a man or a woman.

It also came out clearly that communities expect to work closely with the EHT and the nurse at the nearest health centre. In terms of reporting, the CHW should report to the headmen in the community. As far as health services are concerned, the CHW should report to the nurse at the clinic, and to the councilor in terms of local government.

Communities expect that the central government should pay the CHW and they expect the salary to be between $3500,00 and $5000,00. The CHW will get full support and cooperation from the community in terms of implementation of proposed programmes. The expected improvements upon the introduction of the cadre include reduction in the incidence of preventable diseases such as malaria, diarrhoea, improved quality of life resulting from provision of good water and sanitation programmes; early diagnosis of health problems and addressed in time.

Recommendations:

The following recommendations were made based on the conclusions; 1. The Ministry of Health &CW should introduce the CHW in the shortest time, as possible, since the cadre has been identified as having a crucial role in the position of Primary Health Care.

2. Communities should be involved in the selection of the CHW by identifying the cadres, and then the Ministry of Health interviews those selected.

3. The government should seriously consider the salary range recommended by the communities.

4. The CHW should work closely with the nurse at the nearest health centre, the EHT, the headmen and the councilor.

5. The training curriculum for CHW should include issues such as HBC, report writing, first aid, health education strategies, child sexual abuse, reproductive health and sexuality for the youths.

Abbreviations

VCW Village Community Worker

CHW Community Health Worker

HBC Home Based Care

MOHCW Ministry of Health and Child Welfare

CBD Community Based Distributor

VIDCO Village Development Coordinator