Government of Sierra Leone

Ministry of Health and Sanitation

POLI CY FOR COMMUNI TY

H EALTH WORK ERS
I N SI ERRA LEONE

June 2012
 Acknowledgements

T
he need for clear scientific evidence to inform and support the health policy mak-
ing process has become greater than ever. Integrating Community Health Work-
ers (CHWs) into the national health workforce is perhaps the most complex and
challenging process. It is concerned with key policy issues relating to the work of
CHWs. Therefore, the development of this CHWs policy is another milestone in strengthening our
health system so that quality health services are made accessible at grass roots level.

The development of the CHWs policy is an outcome of a complex process of intensive and exten-
sive consultations, teamwork and cooperation of Local Councils, key stakeholders and health de-
velopment and implementing partners of the Ministry of Health and Sanitation. The Ministry is
therefore appreciative of the incessant effort of all those who contributed in diverse ways to the
development, review and validation of the CHWs policy.

The government is grateful to UNICEF for the financial and technical support provided towards
the development and printing of this CHWs policy.

I wish to extend my profound gratitude to the Top Management Team and the Directorate of Pri-
mary Health Care in particular for being at the forefront in coordinating and finalizing this policy
document thereby ensuring ownership by the ministry.

Alhaji Dr Kisito S. Daoh

Chief Medical Officer

i
 Foreword

H
ealth systems in Sierra Leone are undergoing considerable change, often in a
context of ongoing health sector reforms. In Sierra Leone, decentralization of
health services is very central to these changes, and consequently there is a
need to prepare and empower those working at the district level for their new
responsibilities and tasks.

The development of the Community Health Workers (CHWs) policy is therefore very timely and
represents a significant milestone in our efforts to improve the health status of our women and
children especially at grass root level. The CHWs policy was developed in close partnership with
all stakeholders in the health sector, including our key development and implementing partners
and it is also to be implemented in close partnership with them. My Ministry is committed to sup-
porting the implementation of this important policy which will serve as a guide to implement the
government’s  policy  of  access  to  essential  health  services  at  community  level.  

Frantic efforts will be made to mobilize the resources necessary to ensure successful implemen-
tation of community health work in Sierra Leone. The MoHS recognises that this is best achieved
through active involvement and partnership with other stakeholders. This entails different sector
actors coming together under technical working groups to crystallize a way forward regarding
specific interventions that will help the sector achieve MDGs 4, 5, 6 and 7.

The thrust of the CHWs policy is to firmly address the downward spiral of the health of Sierra
Leoneans,   as   has   been   noted   in   different   assessments.   It   outlines   the   sector’s   strategic   ap-­
proaches in contributing to reducing infant and maternal deaths and health inequalities. As a gov-
ernment, our Poverty Reduction Strategic Plan (PRSP II) which articulates an agenda for change
in the health sector focuses on reducing mortality rates, especially for infants, pregnant and lac-
tating women.

I hope that councils and particularly district health management teams will make optimal use of
this policy in order to enhance their capacity to address the priority health problems that we are
facing every day mainly in the rural communities.

The coming years will be vital in preparing for the challenges we will face in maintaining the mo-
mentum of improvement for our public and patients against a backdrop of a more constrained fi-
nancial climate.

The Ministry of Health and Sanitation acknowledges the concerted effort of working groups, indi-
viduals, and institutions at different levels of the health system that have worked assiduously to

Haja Zainab Hawa Bangura (Mrs.)

Honourable Minister of Health and Sanitation

ii
 Acronyms
ACT Artemisinin Based Combination Therapy
ARI Acute Respiratory Infection
BPEHS Basic Package of Essential Health Services
CBDs Community Based Distributors
CBOs Community Based Organizations
CBPs Community Based Providers
CCM Community Case Management
CCMAM Community Case Management of Acute Malnutrition
CDDs Community Drugs Distributors
CHWs Community Health Workers
CIMNCI Country Integrated Management of Newborn Childhood Illnesses
CLTS Community Led Total Sanitation
CMAM Community Management of Acute Malnutrition
CORPs Community Owned Resource Persons
CSOs Community Social Organizations
DHMT District Health Management Team
DOT Directly Observed Treatment
FP Family Planning
HIV/AIDS Human Immune-Deficiency Virus/Acquired Immunity Deficiency
HMIS Health Management Information System
IEC Information, Education and Communication
IPT Intermittent Preventive Treatment
ITMN Insecticide Treated Mosquito Nets
KMC Kangaroo Mother Care
LBW Low Birth Weight
LLITN Long Lasting Insecticide Treated Nets
MDGs Millennium Development Goals
MICS Multiple Indicators Cluster Survey
MoHS Ministry of Health and Sanitation
NGO Non Governmental Organization
OJT On the Job Training
ORS Oral Rehydration Salts
PHU Peripheral Health Unit
SLDHS Sierra Leone Demographic and Health Survey
SP Sulfaxoxine – Pyrime Thamine
STIs Sexually Transmitted Infections
TB Tuberculosis
TBAs Traditional Birth Attendants
TDT Training of District Trainers
TOF Training of National Facilitators
VDC Village Development Committee
WCBA Women of Child Bearing Age
WHO World Health Organization

iii
 Acronyms

Foreword  …………………………………………………………………………………………………………………………………………….
Acknowledgements  ……………………………………………………………………………………………………………………………..
Acronyms  …………………………………………………………………………………………………………………………………………….
About  This  Policy  ………………………………………………………………………………………………………………………………...
CHAPTER ONE: Community Health Workers Within Public Health Context
In  Sierra  Leone  ……………………………………………………………………………………………………………………………………..
Introduction  ……………………………………………………………………………………………………………………………...
Guiding  Principles  for  the  Functioning  of  CHWs  ………………………………………………………………………...
Roles  and  Responsibilities  of  Various  Actors  ……………………………………………………………………………...
Ministry  of  Health  and  Sanitation  ……………………………………………………………………………………..
Directorate  of  Primary  Health  Care…………………………………………………………………………………...
Directorate  of  Reproductive  and  Child  Health…………………………………………………………………...
Directorate  of  Disease  Prevention  and  Control………………………………………………………………...
Directorate  of  Planning  and  Information…………………………………………………………………………..
Civil Society Organisations/Community Based Organisations/
Local  and  International  NGOs  …………………………………………………………………………………………...
UN  Family  …………………………………………………………………………………………………………………………
University  and  Research  Institutions………………………………………………………………………………...
District  Health  Management  Team…………………………………………………………………………………...
The  Community………………………………………………………………………………………………………………...
The  Community  Health  Workers  (CHWs)…………………………………………………………………………..
CHAPTER  TWO:  Supervision  and  Reporting  of  CHWs  …………………………………………………………………………...
Structure,  Supervision  and  Reporting  ………………………………………………………………………………………..
Reporting………………………………………………………………………………………………………………………….
Supervision………………………………………………………………………………………………………………………..
Periodicity  of  Supervision………………………………………………………………………………………………….
Timing  of  Supervisory  Visits……………………………………………………………………………………………...
Strategies  for  Effective  Use  of  Resources  for  Supervision………………………………………………….
Enabling  Incentives,  Motivation  and  Retention………………………………………………………………...
Monitoring  and  Evaluation  of  CHWs  Work………………………………………………………………………..
Monitoring  Methods………………………………………………………………………………………………………...
Standards  for  CHWs……………………………………………...............................
CHAPTER  THREE:  Guidance  on  Standardised  Training  of  CHWs…………………………………………………………...
Training  of  CHWs……………………………………………………………………………………………………………………...
Module 1: Introducing participants to the standard CHWs training
programme……………………………………………………………………………………………………………………………….
Module  two:  Working  Effectively  with  Communities  and  Households……………………………………….
Module  three:  Water,  Sanitation  and  Hygiene…………………………………………………………………………..
Module  four:  Maternal  and  Newborn  Health……………………………………………………………………………..
Module five: Infant and young child high impact preventive and treatment
interventions……………………………………………………………………………………………………………………………..
Module six: Community Integrated Management of Newborn and Childhood
Illnesses  including  neglected  diseases………………………………………………………………………………………..
Module  seven:  Adolescent  Sexual  and  Reproductive  Health  Rights…………………………………………...
Module  eight:  Sexual  Gender  Based  Violence…………………………………………………………………………….

iv
 About This Policy

T
he purpose of this policy is to ensure standardised implementation of the commu-
nity aspect of the Basic Package of Essential Health Services and effective coor-
dination at all levels. Up till now, capacity building at the community level has
been going on in the absence of specific policy stipulations. This has resulted in
uncoordinated implementation, duplication of efforts and inability to systematically go to national
scale. This policy seeks to bring order by: defining roles and responsibilities of various community
level actors; defining Community Health Workers (CHWs) and spelling out their role, supervision,
monitoring and training requirements.

The policy starts with setting a common understanding of the public health context in Sierra
Leone, who Community Health Workers are, their roles, responsibilities and accountabilities, se-
lection criteria, training, supervision and reporting.

Due to the importance of capacity building for Community Health Workers (CHWs) to enable
them provide appropriate services and support to their communities, this guide further outlines a
10-day standard modular training programme which all CHWs are expected to complete before
achieving recognition as CHWs. Depending on needs in their area of operation, the community
health workers may be taken through additional specialized training in areas such as Community
Integrated Management of Newborn Childhood Illnesses (CIMNCI), Community Case Manage-
ment (CCM), Community Management of Acute Malnutrition (CMAM), Community Led Total
Sanitation (CLTS) and Timed and Targeted Counselling (TTC).

Each training module includes:

 The title
 A brief introduction to the module
 Objectives
 Total time needed to cover objectives
 Module overview that covers high impact interventions and approaches
 Materials needed for training
 Any recommended hand-outs or job aids
 Preparation needed before conducting the training
 Expected outcome of the module.
At the national level, the policy will inform development of other policies and strategies, especially
if they involve working in communities, including cross sectoral ones. The policy will be used to
inform development of a National Community Health

Worker’s  Strategy  and  a  costed  implementation  plan.  The  adoption  and  or  formulation  of  specific  
training curricula, guidelines, protocols and manuals are also expected to be informed by this pol-

1
 About This Policy

icy.

District Health Management Teams, District Councils and other health sector stakeholders at dis-
trict and chiefdom level will use the policy to appropriately implement community health, hygiene
and sanitation promotion, as well as nutrition activities.

2
 CHAPTER 1
Community Health Workers Within the Public Health Context in Sierra Leone

Introduction

H
ealth situation analysis of Sierra Leone reveals facts and figures on country
population, household size, family planning and use of high impact interven-
tions. These facts indicate that the country has a high number of maternal,
new-born and child deaths; very low use of family planning and high number of
teenage pregnancies. The under-nutrition levels are also high. Deaths occur because of low use
of high impact preventive and curative interventions, Many of which are recommended for imple-
mentation at community and household level.

Community Health Workers have an important role in the implementation of these life saving in-
terventions.

Some population, public health facts and figures (SL DHS 2008, MICS 4 2010)
 Estimated total population in 2011 is 5.86 million people.
 An average of 6 people live in one household.
 Seven out of every ten women aged 15-49 years are illiterate while 5 out of 10 men in the
same age group are illiterate.
 Women in Sierra Leone have an average of 5 children, which represents high fertility rates.
 Teenage child bearing is high, as 3 out of every 10 teenage women aged 15-19 years are al-
ready mothers or pregnant with their first child. Women in this age group with no education
are much more likely to have begun childbearing than women with secondary or more educa-
tion.
 Use of modern family planning methods is low, with only 10 out of every 100 married women
aged 15-49 using modern methods. About 27.4% of married women have an unmet need for
family planning (MICS 4, 2010).
 The under-five mortality rate is 140 deaths per 1000 live births; Infant mortality is 89 deaths
per 1000 live births, while Neonatal Mortality is 36 per 1000 live births. The neonatal mortality
accounts for about 40% of all infant deaths (SLDHS 2008)
 Basically 40% of all infant deaths take place during the first 28 days of life. The newborns die
largely from four preventable conditions, namely: birth asphyxia; neonatal infections; hypo-
thermia and low birth weight.
 Skilled attendance during delivery and skilled post natal care attendance during the first 24 to
48 hours offers the best survival lifeline for both the mothers and newborns, since most of the
associated mortality takes place at this same period. However many women and newborns in
Sierra Leone are excluded from the lifeline since only 50.1% of births occur in health facilities
and in total about 62.5% of the deliveries are assisted by a skilled service provider (MICS 4,
2010).
 The coverage with other important Reproductive and Child Health interventions is also low.

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 Community Health Workers within the Public Health Context in Sierra Leone

The DPT3 coverage for children aged 12-23 months is only 71.6% (MICS4, 2010).
 Six months after the universal access campaign in 2010, 87%of households had at least one
LLIN, and 67% had more than one LLIN. 73% of children under five, and 77% of pregnant
women, slept under an LLIN the night before the survey, respectively (LLITN Coverage survey
2011).

Justification for Community Health Workers

Community Health Workers (CHWs) are community based workers that help individuals and
groups in their own communities to access health and social services, and educate community
members  on  health  issues.  The  WHO  defines  CHWs  as:  “they  should  be  members  of  the  commu-­
nities where they work, should be selected by the communities, should be answerable to the com-
munities for their activities, should be supported by the health system but not necessarily a part of
its  organization,  and  have  shorter  training  than  professional  workers”.

Community Health Workers have an important and complementary role to play in health promo-
tion and counselling of care givers in the community to improve health status and to improve ac-
cess to care. The CHW is an essential part of the continuum of care from the community to health
facility and referral level, and for counter referrals.

The interventions delivered by Community Health Workers and included in their training program
are evidence based nutritional, health, water and sanitation interventions, many of which are low
cost and yet high impact, selected to achieve morbidity and mortality reduction. The training and
deployment of CHWs is not a stand-alone project. CHWs are included in the wider health system
and will be explicitly included within the HRH strategic planning at country and local levels.

Human Resources for Health crisis is one of the factors underlying the poor performance of
health systems to deliver effective, evidence-based interventions for priority health problems. Par-
ticipation of CHWs in the provision of primary health care has been experienced all over the world
for decades, and there is evidence that they can add significantly to the efforts of improving the
health of the population, particularly in those settings with the highest shortage of motivated and
capable health professionals. In Sierra Leone, shortage of key health care workers needs to be
addressed by innovative strategies such as development of alternative cadres and task shifting.
The CHW aptly fits this role.

Community Health Workers do not replace the need for quality health care delivery through highly
skilled health care workers. Their placement is expected to play a complementary role. They can
play an important role in increasing access to health care and services, and ultimately, improved
health outcomes. They are potentially an effective link between the community and the formal
health system. CHWs are thus a critical component in the efforts for a wider approach that takes
into account social and environmental determinants of health.

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 Community Health Workers within the Public Health Context in Sierra Leone

Guiding Principles for the Functioning of CHWs

 Community Ownership: Community participatory approaches and dialogue will be used at all
stages of the implementation of CHWs function, hence ensuring that the interventions are needed
and wanted by the communities.
 Equity and Access: Particular effort will be made to reach marginalised communities and
individuals  with  the  poorest  access  to  health  care.    ‘Health  is  a  basic  human  right’
 Support: The Community Health Workers are supported in their work by their own communities,
Peripheral Health Units, and local council structures.
 Partnership: Multi-sectoral partnership will be developed at national and local levels to maximise
effectiveness and efficiency of CHWs.
 Coordination: The MoHS as the central player, leader and the driving force of this initiative,
will ensure functional coordination structures at all levels. The coordination will make it possi-
ble for effective interventions to be selected according to local needs, to ensure maximum cover-
age and coverage of gaps with NO duplication. Further, the coordination will direct advocacy and
fund raising activities.
 Implementation: All health programmes at community level will be implemented through the
Community Health Workers, in accordance with BPEHS, Community Health Strategic and Imple-
mentation plan.
 Integration: Services will be integrated by working within a common framework, standardised
key messages, harmonised training and communication materials, using the CHW as the point of
delivery, and building on existing programmes and activities.
 Strengthening of the Health System: At the same time as improving health at community
level, efforts MUST be made to ensure that referral health care achieves acceptable stan-
dards.
 Rational Implementation: Districts should implement quality lifesaving interventions in a ra-
tional step wise manner. Interventions to be implemented should be based on sound scientific
evidence to enhance effectiveness.

Roles and Responsibilities of Various Actors

Ministry of Health and Sanitation

 Ensure the effective coordination and collaboration for CHW Strategies, with other relevant
Ministries, Donors, Partners, District Health Management Teams and Local Councils.
 Advocate for community level health actions
 Advocate for and ensure sustainable funding for the implementation of CHW strategy and ac-
tion plan.
 Ensure the integration of the CHW into existing Ministry of Health strategic plans and pro-

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 Community Health Workers within the Public Health Context in Sierra Leone

grammes.
 Ensure that all community health interventions are channelled through CHWs and that Com-
munity Based Organisations, Civil Society Organisations and other stakeholder plans are sub-
mitted to relevant Councils and District Health Management Teams.
 Ensure that all community health interventions implemented by partners comply with MoHS
directives and guidelines.
 Provide technical support.
 Support District training for stakeholders and implementers of CHWs programmes.
 Ensure quality control of training and supervisory activities.
 Development and periodic review of integrated CHW training packages, guidelines and super-
vision tools.
 Ensure constant supply of commodities necessary for implementation of the strategy
(registers, reporting forms, defined basic equipment)
 Ensure constant supply of first line ACTs, first line antibiotics, ORS and zinc
 Supervise implementation in collaboration with DHMTs and implementing partners and pro-
vide regular supportive supervision.
 Monitor supervision strategy for CHWs implementation
 Collate, analyse and disseminate CHWs data.
 Formalise information sharing with all partners on progress, outputs and impact.
 Update key core content for all training and reporting materials for CHWs, districts teams and
partners.
 Agree on the key messages (key family practices) and the priority interventions to be included
in CHWs service delivery package.
 Own the CHWs function

Directorate of Primary Health Care

 Develop Community Health Strategy and Implementation plan.
 Take lead in mobilizing resources for the implementation of community health policy, strategy
and implementation plan.
 Take lead in coordination of key stakeholders at all levels.
 Development of materials and job aids at appropriate level of literacy, using local terms in re-
lation to key high impact interventions for advocacy, training, IEC and monitoring in partner-
ship with organisations already implementing at the community level.
 Development of Standardised Simplified Village Registers: activity registers and reporting
forms will be developed and field tested in collaboration with HMIS.
 Development of supervision package as part of the BPEHS package giving guidance to dis-
tricts and partners on models of supervision, training materials to train supervisors and stan-

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 Community Health Workers within the Public Health Context in Sierra Leone

dardised documentation of supervisory activities.

 Review CHW status and coverage of active volunteers for every district annually and assess
completeness and timeliness of Reporting.
 Review supervision coverage by districts for completeness and timeliness of reports.
 Review current coverage of prioritised interventions and compare them to targets
 Review status of activity-related indicators: availability, access, demand, and quality of CHW
services and knowledge of family related health issues (key messages)
 Review major activities in the last plan and assess how well they were implemented
 Assess linkages of CHWs with health system and other sectors
 Collect, collate and disseminate information and plan what is needed to reach targets

Directorate of Reproductive and Child Health

 Support community interventions focused on the health and welfare of women and children,
while ensuring integration of packages.
 Provide technical support and provide direction for the development and deployment of poli-
cies, strategies, standards and tools at community level for: reproductive and adolescent sex-
ual health; immunization; integrated management of neonatal and childhood illnesses; and
child nutrition and management of under-nutrition.

Directorate of Disease Prevention and Control

 Ensure quality of programmes and interventions involving control, elimination and eradication
of diseases of public health importance by the CHW at community level.
 Development and deployment of policies, strategies, standards and tools for: prevention, con-
trol and elimination of malaria; community response to the HIV/AIDS epidemics; distribution or
observation of treatment for tuberculosis and leprosy or neglected tropical diseases and; Inte-
grated Disease Surveillance and Response.

Directorate of Planning and Information

This directorate will be responsible for coordinating the development of sector-wide policies and
systems for health development, health financing and management information systems related
to CHWs.
 Coordinate collaboration with all technical directorates in the development, monitoring and
evaluation of sub-sector policies, strategies and operational plans in order to ensure harmony
 Development of tools for monitoring and evaluation, national health policy and strategic and
operational plans to include CHWs
 Health sector financing unit to lead the development, monitoring and evaluation of health sec-
tor financing policy for the CHWs aspect of BPEHS

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 Community Health Workers within the Public Health Context in Sierra Leone
 Health management information unit to lead the development, monitoring and evaluation of
health and management information systems for a community health information system
linked to HMIS.

Civil Society Organisations/Community Based Organisations/ Local and International

NGOs
 Provide technical support, guidance and financial support.
 Technical guidance on execution, monitoring and evaluation of CHW implementation.
 Support quality assurance of all aspects of implementation
 Comply with MoHS directives and circulars regarding community health workers, community
health interventions and community case management.
 Ensure all community health activities are channelled via the community health workers.
 Coordinate activities with DHMT and other partners to ensure EFFECTIVE coverage of inter-
ventions and avoidance of duplications.
 Submit and agree on plans for implementation with MoHS and relevant DHMTs
 Ensure that content of all key messages, training and supervision packages are in line with
MoHS Directives and Guidelines
 Report activities and data as defined by MoHS in HMIS compatible format in timely and com-
plete manner.
 Ensure quality of services according to national treatment guidelines
UN Family
 Provide technical support, guidance and financial support to MoHS.
 Technical guidance on execution, monitoring and evaluation of CHW implementation.
 Support quality assurance of all aspects of implementation, including quality of services ac-
cording to national treatment guidelines and ensure within the scope of BPEHS
University and Research Institutions
 Play key role in the coordination and implementation of M&E
 Carry out essential operational research that will improve on existing interventions and sup-
port their delivery mechanisms
 Maintain constant dialogue with partners to ensure that results are communicated adequately
and that the research agenda is reflecting the implementation needs.

Local Councils
Work in collaboration with the District Health Management Team (DHMT), other stakeholders and
communities to:

 Participate in the selection of community members to be trained as Community Health Work-

ers.

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 Community Health Workers within the Public Health Context in Sierra Leone
 Undertake community sensitization on the roles and responsibilities of CHWs and ensure
compliance.
 Formulate by-laws governing provision and use of health care services in the communities.
 Conduct advocacy and resource mobilization for training, support, motivation, and incentive
schemes for CHWs.
 Conduct monitoring of the work of CHWs, identify gaps and challenges and recommend solu-
tions.

District Health Management Team

 Ensure the effective coordination of the CHW policy and practice guide at District level within
the context of the BPEHS
 Advocate to garner support for the implementation and expansion of the policy in the District.
 Ensure that all community based health activities are channelled via the CHWs
 Ensure that ALL CBO, CSO and NGO partners submit their plans and budgets for inclusion in
the Local Council Health Plan, and that District health priorities are addressed, and gaps filled.
 Maintain  a  register  of  CBOs/CSOs/NGO’s  operating  in  the  District  and  their  activities.
 Maintain a register of CHWs in the district by location and trainings undertaken
 Select supervisors using defined selection criteria
 Map villages covered by each health facility and to which each CHW is attached.
 Train CHWs and ensure norms, standards and quality assurance
 Ensure that CHW activities address the disease burden in their villages
 Collate monthly and quarterly data, analyse, summarise and disseminate
 Provide feedback to supervisors, volunteers and health facilities and the community.
 Document lessons learned and communicate these to ensure improvement in quality of CHW
implementation

The Community
Families, individuals and their organizations (e.g. women groups), leaders (political and religious)
and health and social structures (Village Development and PHU Management Committees) are
crucial partners in implementation by:
 Prioritising, promoting and/or providing prompt and adequate treatment, particularly for high-
risk groups and immediate referral in case of non-response or danger signs;
 Prioritising preventive measures to protect family as well as community with special emphasis
on the risk groups;
 Providing oversight of community health workers.

The Community Health Workers (CHWs)

Any and all persons appropriately trained and providing health care or distributing health,

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 Community Health Workers within the Public Health Context in Sierra Leone

nutrition, hygiene and sanitation commodities at community level is hereby officially re-
ferred to as a Community Health Worker (CHW).

Definition
A Community Health Worker is a community member who is selected by the community and will
be trained to provide basic essential health services and information at community level. CHWs
are not transferable to other villages unless formally endorsed by the Ministry of Health and Sani-
tation. The basic package that he/she can provide has been defined by the Ministry of Health and
Sanitation.

Sierra Leone has many types of community members working under different names and labels.
These include Traditional Birth Attendants (TBAs), Community Drug Distributors (CDDs), Com-
munity Based Distributors of contraceptives (CBDs), Community Based Providers (CBPs), Blue
flag volunteers, Red Cross Volunteers and Community Owned Resources Persons (CORPs).
These community members perform specific but different roles that are all linked to health.

In order to achieve recognition as CHWs they will all need to undergo a basic 10 days standard-
ised CHWs training programme as specified in chapter three of this policy and practice guide.

Selection
One Community Health Worker will be selected to serve a population of between 100-500 people.
The Community Health Worker is selected by the community that he/she serves led by Village
Health Committees, and should reflect the linguistic and cultural diversity of the population
served. The selection process must ensure gender parity.

He/she must fulfil the following criteria:

 Should be exemplary, honest, trustworthy and respected
 She/he should be willing to serve as a volunteer
 Must be a resident of the village and willing to work with the community
 Should be available to perform specified CHW tasks
 Should be interested in health and development matters
 Should be a good mobiliser and communicator
 May already be a CH Volunteer, TBA, condom distributor or youths trained in life skills
 Ideally, should be able to read and write at least the local language
 Permanent member of the community aged 18 years and above
 Physically, medically, mentally and socially fit to provide the services
 Ideally has been involved in community projects in the past

10
 Community Health Workers within the Public Health Context in Sierra Leone

Key Duties, Roles & Responsibilities

Conduct community sensitization and advocacy for:
 Mobilising communities for appropriate environmental sanitation and hygiene practices.
 Mobilising communities to set up and support community owned emergency referral system
including setting up a fund.
 Adolescent Sexual and Reproductive Health.
 Child protection issues
 Use of scheduled outreach services to the communities
 Linking up with Village Development Committees (VDCs).

Conduct home visits to promote:

 Use of Insecticide Treated Mosquito Nets (ITNs)
 Household water treatment
 Hand washing with soap at the household.
 Appropriate hygiene and sanitation practices, including: food hygiene, disposal of excreta +
for child, etc.)
 Birth preparedness for pregnant women
 skilled Post natal care for both mother and new-borns.
 Initiation of breastfeeding within first hour of delivery and appropriate temperature
management for the newborn
 Exclusive breastfeeding for children 0-5 complete months
 Adequate nutrition 6-11 months
 Timely utilization of immunization services
 Build capacity of the family members to appropriately take care of newborns, U5 children,
pregnant women and other vulnerable persons.
 Build capacity of the family members to recognize and act on danger signs (especially for
newborns, pregnant/postnatal women and U5 children)
Provide:
Oral Rehydration Therapy and Zinc for diarrhoea management
Artemisin-based Combination Therapy for malaria
Antibiotics for U5 pneumonia
Screening services for acute malnutrition, including MUAC measurements
Growth monitoring to identify early referrals
Family planning methods including condoms and oral contraceptive pills
Fefol, deworming tablets, Vitamin A, ORS, Ivermectin

11
 Community Health Workers within the Public Health Context in Sierra Leone
Defaulter tracing for Immunization, Vitamin A, Severe Acute Malnutrition treatment

Report:
 Vital events such as births, deaths including possible maternal deaths, outbreak or epidemics,
persistent cough, passing of frequent stools

 Their (CHWs) activities in the community.

12
 CHAPTER 2
Supervision and Reporting of Community Health Workers

Structure, Supervision and Reporting

 Each CHW will be attached to the nearest PHU with a trained supervisor.
 The PHU will keep a list/register of active CHWs and the trainings they have undertaken
 The DHMT will keep an updated list of CHWs from all health facilities that will include former
CBDs, CBPs, Blue flag volunteers, Red cross volunteers, and CORPS
 Each PHU and the DHMT should display a map of catchment villages with CHWs. This should
be updated quarterly.
 The map should include information on distance, terrain, population of the community and ser-
vices available
 The local council should provide a supportive environment for supervision.

Reporting
 Each village will have a simple Register.
 Each CHW will also have a Register. They will report activities carried out during the month,
commodities distributed and treatments given.
 The CHW will report his/her activities during the month, births and deaths, and the sick they
have treated. This will be in a standard format. For those CHWs in geographically hard to
reach areas, districts and partners will find innovative methods such as SMS reporting to en-
sure reports of a minimal standardized data set is received complete and on time.
 Those CHWs receiving commodities and drugs will sign the PHU commodity register on re-
ceipt and will account for supplies received monthly.
 The PHU will report Key CHW activities and coverage monthly to the DHMT.
 NGO’s  supporting  CHW  activities  will  submit  copies  of  reports  to  linked  PHU  to  be  included  in  
monthly data.

Supervision
Supervision is crucial for maintaining correct performance and motivation of CHWs. It is important
to prioritize and focus on those activities and tasks that are the most important for CHWs and the
health of the communities they serve. The tasks or items that need to be supervised are likely to
change over time. Supervision is geared to help CHWs provide better services to their communi-
ties and build their skills and knowledge and to assess and improve the quality of CHW imple-
mentation.

Periodicity of Supervision
 CHWs will be supervised by the in charge of the PHU to which they are linked once per
month.

 Trained peer supervisors selected from trained existing CHWs will supervise CHWs and re-
port to PHU based supervisors
 Zonal supervisors will also provide additional supportive supervision to CHWs and their PHU

13
 Supervision ad Reporting of Community Health Workers
based supervisors
 Supervisors will visit CHWs in the community at least quarterly.
 Additional supervision will be provided at quarterly meetings at Chiefdom level.
 The council will also provide additional supportive supervision through its chief level struc-
tures.
A supervisor should ensure that all CHWs have the necessary support they need in order to im-
plement a quality CHW implementation and accomplish activities.
This support includes:
 Adequate supplies of essential equipment, supplies, materials.
 Resources for regular supervision.
 A functional system for distributing essential materials and supplies.
 An adequate budget for routine activities.
 Clear guidelines on routine activities and any reporting requirements.

Selecting who will conduct supervision

 Zonal supervisors

 Supervisors will mainly come from PHU to which the CHWs are attached

 Supervisors with experience of working with CHWs

 All supervisors should receive training on how to conduct supportive supervision using stan-
dardized supervisory skills checklist.

Timing of Supervisory Visits

When developing a schedule for CHW supervision visits, DHMTs and supervisors should take
into account a number of factors to help prioritise when visits are done:
 Results of previous supervisory visits as CHWs identified as having problems should be vis-
ited more regularly, to give them support and guidance
 Newly trained CHWs need more frequent follow-ups.
 Availability of supervisors. Supervision can only take place when supervisors are available
and able to devote sufficient time to assess all areas to give feedback and solve problems.
 Availability of CHWs. CHWs are volunteers. Therefore, supervision should be planned when
CHWs are available.

Availability of Resources
Lack of finances for supervision affects the regularity and frequency of visits and will eventually
affect the quality of care provided by the CHW. It is essential that District Health Management
Teams budget and plan for supervision in their annual Local Council Health Plans. There is need
for the plans to provide a budget line for DHMTs supervision of CHWs

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 Supervision ad Reporting of Community Health Workers

Strategies for effective use of resources for supervision

 Supervise CHWs once per month when they come to the PHU or assist with Outreach.
 Use every opportunity when a CHW comes to the PHU for other reasons or if the Health
worker goes to the community.

Methods
1. Supportive supervision to be used in all aspects of monitoring.
2. Observation of practice.
3. Talking with CHWs helps assess their knowledge. It also allows supervisors to understand
how CHWs see their activities, their difficulties and what they see as possible solutions.
4. Review of records.
5. Community discussion with key informants about how they perceive services offered by the
CHWs.
6. Use a combination of some of these methods.

Enabling incentives, motivation and retention

Motivations for Community Health Workers are both monetary and non-monetary. CHWs are Vol-
unteers. However, MoHS recommends that they ALL receive a standard minimum motivation
package.
The MoHS has defined this minimum motivation package to include, for purposes of identity,
standardised T-shirt, badge, caps; and for cultivating a sense of achievement, certificates/awards
and letters of recognition. The package includes the following:

 Basic requirements to carry out CHW function (Standardised uniform, ID, Standardised bag and kit
using MoHS CHW logo, Registers and IEC materials.
 Lunch and travel allowance whilst carrying out outreach and visits to health centre.
 Health worker supervision and mentoring – technical support
 Activity and performance related incentives may be paid. Decision on payment of incentives,
amount and modalities to use will be decided by local authority structures and community.
 Recognition by Authorities and their own communities.
 Access to Government programs, income generating schemes and other microfinance and credit
schemes
 Community reward – such as community digging, seeds, livestock
 Free treatment for the CHW and immediate family.
 Competitions with prizes for the best performing CHWs.

15
 Supervision ad Reporting of Community Health Workers
It is also recommended that Districts/Councils and implementing partners incorporate appropriate
and affordable motivating and enabling factors and activities into their implementation plans.
Partners must assure provision of appropriate core supplies and equipment to ensure CHW func-
tionality.
Certification/Recognition by the MoHS and community members after training allows for visibility
and quality assurance. Opportunities for professional development and acquisition of skills are
very strong motivators, and these include opportunities for career mobility (becoming a supervi-
sor) and professional development, such as opportunities for continuing education, professional
recognition, and opportunities of access to educational and training scholarships and exchange
visits by CHWs to see best practices.
CHWs will be provided with the means of transport in the form of fares or in some cases a bicy-
cle. In hard to reach areas the MoHS recommends that if funding allows, CHWs are loaned a mo-
torbike. If they cease to act as a CHW, the motorbike will be passed on to the new CHW taking
over his/her role. Those CHWs working in hard to reach areas, will be given the means of com-
munication especially Cell phones and/or credit, as this will also facilitate referral.

Monitoring and evaluation of CHWs work

The MoHS recommends that monitoring
 Must be done continuously.
 Collects information on CHW activities implemented and the results of those activities.
 Will be used to make immediate programmatic decisions.
 Data will be used to improve or correct activities that are not working – and to know when to
continue activities that are working.
It is important to track whether activities that were planned are actually carried out. This informa-
tion should be recorded and provided to the DHMT for activities such as training courses con-
ducted, supervisory visits made, medicines and supplies distributed, counselling materials distrib-
uted, counselling sessions done, and home visits made.
Records and reports of supervisory visits should provide information on activities completed and
indicators measuring availability, access, demand and quality (such as supplies available, health
workers trained, supervisions conducted, observations made during supervisory visits). Financial
indicators assess to what extent the budget planned for certain activities has been disbursed.

Monitoring methods
The MoHS recommends that the following methods be used:
Record review
This includes CHW registers, monthly summary reports, PHU based morbidity and mortality data,
data on referrals, training attendance reports, training post-tests, reports from follow-up after train-
ing, medicines stock data, project status reports, and reports of supervisory visits. Training and

16
 Supervision ad Reporting of Community Health Workers

drug management records are used for determining numbers of CHWs trained and medicine
availability.
Administrative reports provide information on resource availability (e.g. numbers of health workers
for supervision, CHWs still active, funds, equipment and spending). Project reports may provide
information on activities completed.
In PHU facilities, record review indicating the number of cases by classification, including a sum-
mary of the number of cases seen by each CHW and how they were managed. Facility-based
data on family planning, antenatal care, HIV/AIDS and postnatal care should also be reviewed.
Hospital-based records may allow review of the management of severely ill children and pregnant
women and tracking of changes in the number and type of referrals over time.
The CHW records births, deaths, including possible maternal deaths, attendance at antenatal and
postnatal checks, the place of delivery and outcome for both the mother and infant.

Reports of supervisory visits

These should describe activities that are going well, problems, and whether problems have been
resolved. There will be data on supply management, meeting with community groups and health
education sessions, etc. To avoid variability in the quality of supervision, DHMT should give stan-
dardised monitoring checklist, and report forms together with clear instructions to supervisors, for
using them. All supervisors should be trained in how to use them.

Routine reporting systems

Routine community based reporting systems are already in use in Sierra Leone and are used to
collect data regularly from all health facilities for community activities. With the introduction of In-
tegrated Community Case Management (ICCM) and community based new-born care, the report-
ing forms will be updated so that information from CHWs on the number of cases of sick children
seen and referred can link directly into HMIS.
Monitoring data should be collected and analysed quarterly. DHMTs should review training re-
ports to see whether courses were conducted as planned and to record the number of people
trained and their names in the CHW register. If the course was not conducted or there were sig-
nificant problems, the DMO should investigate and try to solve the problem before it impacts fu-
ture courses. Monitoring should follow closely the plan of activities. Routine reports should be re-
viewed as soon as they are available.
Monitoring of implementation is coordinated by the DHMT and DPHC in Collaboration with the
Directorate of Planning
Monitoring data is often collected and NEVER used. The most important step at district and na-
tional levels, is to review the data, interpret it, and use the information to improve the CHW Imple-
mentation (INFORMATION FOR ACTION)
To ensure that monitoring data will be used, DHMTs should have a clear plan for recording, sum-
marizing, analysing, reviewing and interpreting the monitoring data regularly according to sched-

17
 Supervision ad Reporting of Community Health Workers

ule. It should be simple, feasible with local resources and skills, and should not require too much
time to complete. ALL data collection for different programme areas carried out by CHWs should
be linked.
The MoHS recommends the following data recording tools for the CHW:
 Village register
 CHW treatment Register
 Summary Sheets from PHUs and Districts.
 A computerized database, in which data are entered into a spread sheet programme.

Standards for CHWs

All CHWs must keep source of clean water for washing hands
All CHWs should construct a latrine or similar facility at their home
ALL CHWs should have LLIN hanging and used every night
ALL CHWs must know Key Health messages (Key family practices)
Standards for CHW Kit
All CHWs will receive a standard Kit on completion of basic training
ALL Partners will supply the same minimum kit
The Kit will comprise T-shirt, cap, badge, Bag Register, Health Promotion Flip charts, Standardised IEC
materials and Job Aids, Soap
Standards for CHW Training
All CHWs will have 10 days standard training in health promotion, including interpersonal communica-
tion, which conforms to agreed norms and standard content, duration and ratios of CHWs to facilitators)
Additional modular training will be given for additional roles and responsibilities (family planning, CIM-
NCI, CLTS, CMAM, TTC, etc).
Clear selection criteria will be used for selecting the most appropriate CHW for the additional training
Quality assurance will be applied for norms and standards of additional training
Minimal skills required by CHWs for Core Functions
Knows roles and responsibilities
Able to fill out CHW register
Knows Key Messages (Key Family practices)
Knows which diseases to report on
Knows how to read MUAC tape/strap
Knows how to check for oedema
Knows basic simple first aid techniques
Necessary tools and Equipment for CHWs
Every CHW has a Job aid for identifying children, new-born and women with danger signs available and
immediately accessible in CHW kit.
Every CHW will have a standardised Colour Coded MUAC tape/strap with standardised MoHS/WHO cut
offs for Malnutrition and severe malnutrition
Every CHW carrying out ICCM has a means of counting respiratory rate which is immediately available
(respiratory timer, watch with second hand, mobile phone with timer function)

18
 Supervision ad Reporting of Community Health Workers

Availability of essential drugs

Community case Management
Essential drugs for ICCM (ACT in 2 strengths, 1st line antibiotic for pneumonia in appropriate strengths,
zinc and ORS,) are always available and free of charge to the family.
The defined Essential drugs are available in the CHW drug Kit and drugs are not expired and all recom-
mended strengths present. Other essential drugs and supplements include Vitamin A and de-worming.
All stock out will be documented and counted
CHW Core Activities
Social mobilization activities
Mami en Pikin Welbodi Wik- 6 monthly
Child Health Campaigns - 6 monthly
Other mass campaigns as necessary
Outreach monthly
Health promotion talks (individual and group talks covering areas identified during community mapping) -
monthly
Active case finding and defaulter tracing
Early Warning and Community Surveillance Activities
For reportable diseases - Continuously
Registration
Pregnant women, Immunisation, births and deaths as necessary at least monthly/weekly?
Home Visits
For update of village CHW register - Annually
Pregnant women 4 times during pregnancy and 4 times post partum
Newborns 3 times in first week of life
Follow-up of Severe Acute Malnourished children receiving treatment at PHU
Follow up discharged patients as directed by health workers
Direct observation of treatment as directed by supervisor
REPORTING
Reporting By CHWs
Diseases under surveillance - Immediately
CHW Activities - Monthly
SAM in community - Immediately
Births and deaths - Monthly
Children in school - Quarterly
Village register - Annually
Reporting By Partners
Quarterly to DHMT
Reporting By Districts
CHW Quarterly to National level
HMIS according to national requirements monthly
Supervision
All CHWs will be supervised by PHU monthly meeting when registers and reports will be checked and
on job training and supervision will be carried out
All CHWs will attend quarterly supervision meeting
CHWs will receive supportive supervision in the community at least once per year

19
 Supervision ad Reporting of Community Health Workers

Review Meetings
Districts will hold quarterly CHW review meetings where data from CHW implementation, including
from NGO/CBO, CSO partners will be presented.
National task force will hold biannual review meetings. These meeting will assess coverage, completeness
and timeliness of reporting from districts, quality and lessons learned for implementation to be applied.
Monitoring
All levels will have a monitoring and evaluation plan for CHW implementation. Targets will be set, re-
viewed and adjusted annually
Integrated Community Case management

Only CHWs who have completed basic health promotion training followed by Case management training
will be allowed to treat members of the community following the training guidelines.

20
 CHAPTER 3
Guidance on Standardised Training of Community Health Workers

Training of CHWs
The Training Strategy for CHWs is to retrain ALL CHWs regardless of whether they have been
trained in the past. They will go through a 10 day basic training course.

Training will be in accordance with the norms and standards set by the Ministry of Health and
Sanitation, and using materials with standardised key messages that meet MoHS standards.
Each training session shall train no more than 30 CHWs per group. Training will be phased into a
Training of national Facilitators (TOF), Training of district Trainers (TOT), Training of PHU Super-
visors and finally training of CHWs.

Partners are directed NOT to start training until they can ensure that ALL essential supplies are
available for the CHWs to immediately start implementation.

CHWs will receive integrated refresher training twice every year in addition to monthly support
supervision and On the Job Training (OJT).

The   basic   10   days’   training   will   be   made  up   of   6   modules.  The  training  will   start   with  a  pre-test
and end with a post test. In addition, there will be end of training evaluation. Successful partici-
pants will be issued with a standard certificate of participation. Each module provides an outline
that includes:
 The title
 A brief introduction to the module
 Objectives
 Total time needed to cover objectives
 Module overview that covers cost effective and high impact interventions and approaches
 Materials needed for training. The materials need to be illustrative/ practical
 Any recommended handouts
 Preparation needed before conducting the training and,
 Expected outcome of the module.
 End of module assessment/evaluation
The expected outcome of the module effectively translates policy on training as it relates to the
module into CHWs practice once working for their communities. Any needed further training will
be specified alongside the expected outcomes.

21
 Guidance on Standardised Training of Community Health Workers

Module 1: Introducing Participants to the Standard CHWs Training Programme

Introduction:
Improving the health of the nation is one of the key priorities of our Government. Considerable
progress has been made in reducing the high infant and maternal mortality rates, increasing im-
munisation coverage rates and increasing the use of insecticide treated bed nets. Nonetheless,
women continue to die at childbirth and too many children die of easily preventable diseases for
which cost effective interventions exist. Much remains to be done with regard to tackling ill health
related to poverty.

The Government has launched the National Health Sector Strategic Plan which guides the Minis-
try of Health and Sanitation (MoHS) and its partners in attaining the health related Millennium De-
velopment  Goals  (MDGs).  It  reflects  the  Ministry’s  fundamental  belief  that  health  is  a  basic  human  
right. In this regard, therefore, health services should be made available, accessible and afford-
able to all people without discrimination.

This module introduces the 10 days standard CHWs training programme and gives practical de-
tails on how the programme will be delivered for both participants and facilitators.

Objectives:
 To allow participants and facilitators to get to know each other.
 To allow participants to state their workshop expectations and any fears and agree together
how they will be managed
 To agree ground rules for the whole programme
 To summarise the public health policy guiding the CHW programme in Sierra Leone
 To recognise and understand the valuable role that Community Health Workers will play in
improving the health and wellbeing of their communities
 To share the training programme and training manual with the participants, ensuring that all
participants are aware that full attendance is required in order to complete the programme.
 To explain how the training programme will be conducted
 To administer a pre-test.

Time: 2 hours

Module overview:

 Welcome, introductions and getting to know each other.

 Ground rules and participants expectations.
 Policy overview and role of the community health worker.
 The 10 days training programme in detail.

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 Guidance on Standardised Training of Community Health Workers

 Wrap up and deal with any final queries.

 Administer pre-test.
Materials

 Flipchart paper, marker, pens, name tags, pre-test questionnaires and copies of training pro-
gramme.
 Illustrative visual aids

Hand outs
 CHW policy
 CHWs training manual

Preparations
 Ensure all required materials and handouts are available and enough.
 Visit the training venue and ensure sitting arrangements are in order.
 Meet all facilitators and organisers to ensure that all logistics, funding and food provisions are
taken care of.

Outcome of the module

 Know their roles and responsibilities
 All  participants  and  facilitators  know  each  other’s  names  and  where  they  are  from
 Participants can describe the role of the Community Health Worker and how it will contribute
to improve health, by giving specific examples
 Ground rules are written down and agreed for the whole programme
 Participants fears and expectations have been discussed and agreement reached on how
they will be managed
 All participants agree to attend the whole training programme

23
 Guidance on Standardised Training of Community Health Workers

Module 2: Working Effectively with Communities and Households

Introduction
Communication for behaviour change is a skill that Community Health Workers (CHWs) will need
in order to effectively serve their communities. Communicating for behaviour change (also called
BCC – Behaviour Change Communication) is important for the adoption of high impact interven-
tions at the household and community levels.

Objectives
 To build the capacity of participants to better apply the basic principles of communication for
behaviour change.
 To  improve  participants’  skills  in  the  selection  and  appropriate  use  of  IEC  (information  edu-­
cation communication) materials to support health promotion activities.
 Build CHWs capacity on correct interpretation of IEC materials
 Train CHWs on household mapping, identification of vulnerable and marginalized house-
holds and availability of relevant support services.

Time: 6 (six) hours

Module overview
 Basic communication and behavioural change
 Selection and appropriate use of IEC materials
 Household mapping and identification of vulnerable and marginalized households including
child labour and child abuse
 Practicals on mapping, referral and identification
Materials
Flip chart, markers, starch, rope, paper, stick, masking tape, blackboard and chalk
Handouts
IEC materials, hand bills and posters
Preparation
 Ensure that training materials and handouts are prepared and ready for use
 Identify some vulnerable households to use for practicals and obtain their consent
Outcome of the module
 CHWs can effectively communicate and positively change community and household be-
haviours in support of health promotion activities.
 CHWs can conduct household mapping.
 CHWs can identify vulnerable and marginalized households and groups.
 CHW can facilitate access to services by vulnerable groups.

24
 Guidance on Standardised Training of Community Health Workers

Module 3: Water, Sanitation and Hygiene

Introduction
Diarrhoea is one of the leading causes of deaths in children under the age of five in Sierra Leone.
The preventive measures against diarrhoea are simple, practical and possible in all Sierra
Leonean homes. This module aims at preparing Community Health Workers to tackle water, sani-
tation and hygiene related problems, including emergencies in their communities.

Objectives
 To  increase  participants’   knowledge  of   improved   water   sources  and  household   water   treat-­
ment.
 To increase participants knowledge of improved sanitation, proper food hygiene practices
and personal hygiene.
 To  build  participants’  capacity  to  promote  household  hand  washing  with  soap  and  water.
 To  build  participants’  capacity  for  emergency  preparedness  and  response.
Time: 6 hours
Module overview
 Household water treatment and access to improved water sources
 Use of improved sanitation and proper food hygiene practices
 Hand washing with soap
 Emergency preparedness and response for disease outbreaks
(note: oral Rehydration Therapy and Zinc for Diarrhoea management is covered in session 6.2)
Materials
Flip charts, Markers, Pencils, Soap and water (preferably flowing water, e.g. bucket with attached
tap)

Handouts:
CHWs manual

Preparations
 Ensure physical availability of all materials listed above
 Identify locally available sources of water for field visits
Outcome of the module
 CHW will be an agent for behaviour change in their communities towards: use of water from
safe sources; household water treatment; use of improved sanitation and food hygiene prac-
tices; and safe disposal of refuse and other human waste.
 CHW will be a change agent for hand washing with soap and water.
 CHW can initiate community based emergency preparedness and response to disease out-
breaks in general.

25
 Guidance on Standardised Training of Community Health Workers

Module 4: Maternal and Newborn Health

Introduction:
Sierra Leone has one of the highest proportions of women and newborn dying during pregnancy,
childbirth and the immediate period thereafter. Many of the women die from bleeding, malaria,
fits,   infection,   unsafe   abortion   and   prolonged   labour.   Many   babies   die   in   the   mothers’   womb   or  
before they reach 1 month (neonate) because of infection, failure to breathe at birth, low birth
weight (<2.5 kg) and being born too early (< 37 weeks). This module aims to provide CHWs with
the skills to implement proven community level interventions that can help reduce these deaths.

Objectives:
 To train participants to sensitise their communities on the importance of: at least four (4) fo-
cused antenatal care visits during pregnancy; clean assisted delivery in recognized health
facilities; skilled attendance during the first 24-48 hours after delivery; community based es-
sential newborn care and timing, spacing and limiting of pregnancies.
 To train participants on the recognition of danger signs in pregnancy, during and after deliv-
ery for both mother and baby that should be immediately referred.
 To train participants on the provision of FREE: IPT, Ferrous and Folic acid and Multivitamins
to pregnant women; Post-Partum Vitamin A to the mothers and; community based family
planning services.

Time: 6 hours
Module overview
 Focused Antenatal Care and provision of FREE IPT, Ferrous and Folic acid and Multivita-
mins to pregnant women.
 Skilled attendance during delivery in Health Facilities.
 Skilled attendance during first 24-48 hours post partum period and provision of Post Partum
Vitamin A.
 Essential neonatal care, including Initiation of breast feeding within first hour of delivery and
temperature management.
 Danger signs and early referrals of mother/baby
 Community Based Family Planning by CHW
Materials
CHWs training manual; flipcharts and posters showing pregnant women, child birth, neonatal
care; FP methods and job-aides; checklist for provision of FP methods by CHWs; Vitamin A; SP
for IPT; FeFol; LLITN; and reporting tools for FP, Vitamin A, SP, FeFol, LLITN, etc.
Preparations
 Ensure all required materials and handouts are available and enough.

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 Guidance on Standardised Training of Community Health Workers

Outcome of the module

 Participants can sensitise their communities on importance of at least four (4) focused ante-
natal care visits during pregnancy; clean assisted delivery in recognized health facilities;
skilled attendance during the first 24-48 hours after delivery; community based essential
newborn care; and timing, spacing and limiting of pregnancies.
 Participants can recognize danger signs in pregnancy, during and after delivery for both
mother and baby that need immediate referral.
 Participants can provide FREE: IPT, Ferrous and Folic acid and Multivitamins to pregnant
women; Post-Partum Vitamin A to the mothers and; community based family planning ser-
vices.
 CHWs able to refer sick members of the community appropriately.
 CHWS able to undertake follow-ups and ensuring at least 4 focussed post natal care visits.

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 Guidance on Standardised Training of Community Health Workers

Module 5: Infant and Young Child High Impact Preventive and Treatment Interventions

Introduction
Community Health Workers can play an active role in promoting good nutrition, growth and pro-
tection of the infant and young children against preventable diseases and to ensure that each
time a child is seen in the clinic for treatment, the visit is not a missed opportunity to immunize the
child or address a nutrition problem.

Objectives
 To train CHWs on skills and knowledge that are needed for them to effectively mobilize com-
munities and mothers to adopt exclusive breastfeeding and age appropriate complementary
feeding.
 To train CHWs on skills needed to identify and refer severe acute malnourished children, mo-
bilize communities for the uptake of de-worming and vitamin A supplementation, carry out
defaulter tracing for immunization, CMAM and Vitamin A supplementation
Time: 4 hours
Module overview
 Exclusive breastfeeding for children 0-6 months;
 Breastfeeding for children 6-14 months and age appropriate feeding thereafter, including
home fortification to improve quality of complementary food.
 Immunization, de-worming and Vitamin A.
 Community-based Management of Acute Malnutrition, starting with identification of cases

Materials
Counselling cards, posters, dolls, Towel/blanket, MUAC tapes, Under-five cards, flip charts and
markers
Handouts
CHWs manual, Counselling cards, posters, MUAC tapes
Preparation
 All materials needed for the training are available.
 Identify cases of acute malnutrition in advance to explain clearly to the CHW.
Outcome of the module
 CHWs can mobilize communities and mothers to adopt exclusive breastfeeding and aide ap-
propriate complementary feeding and use home fortification to improve complementary food.
 CHWs can carry out defaulter tracing for immunization and mobilize communities for the up-
take of de-worming and vitamin A supplementation.

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 Guidance on Standardised Training of Community Health Workers

Module 6: Community Integrated Management of Newborn and Childhood

Illnesses, Including Neglected Diseases

Introduction
The main killers of under five years old children in Sierra Leone include Malaria, Diarrhea, Acute
Respiratory Infections, neonatal infections, birth asphyxia and low birth weight. For most of these
conditions, malnutrition is a compounding factor.

Malaria is a very serious disease that starts with fever. It is common in Sierra Leone throughout
the year, but infection is higher at the beginning and end of the rainy season. Malaria is the num-
ber one killer of under five years old children in Sierra Leone. Malaria is transmitted by the bite of
an infected female Anopheles mosquito. When an infected mosquito bites a person, it injects the
malaria  parasite  into  the  person’s  blood.    Only  the  female  anopheles  mosquito  spreads  malaria.  
Mosquitoes breed in stagnant waters. Everyone in the family can get malaria. However pregnant
women and children under five years are the most vulnerable to malaria. Many lives can be saved
by preventing malaria and treating it early. Children and their family members have the right to
quality health care for prompt and effective treatment and malaria prevention.

Community based high impact interventions against these conditions and diseases exist, hence
the purpose of this module in building the capacity of Community Health Workers in Community
Integrated Management of Newborn and Childhood Illnesses (C- IMNCI).

Apart from Malaria, ARI and Diarrhoea (see previous modules) there are other communicable dis-
eases that can result in sickness and death. This module aims to provide CHWs with information
and skills to implement proven community level interventions that can prevent and/or reduce
these sicknesses and deaths.

Objectives
 To increase participants knowledge on malaria prevention and control.
 To build participants skills in promoting consistent and correct use of Insecticide Treated
Mosquito Nets for pregnant and lactating women and children under the age of five.
 To sensitise participants on community based management of malaria.
 To train CHWs on Community Integrated Management of Newborn and Childhood Illnesses
(C-IMNCI).
 To train CHWs on the identification of general danger signs and timely referral of newborn
and other under five children to the appropriate health facilities for treatment.
 To train CHWs on the identification of acute malnutrition, defaulter tracing for malnutrition
and appropriate referral.
 To train CHWs on identification of LBW (low birth weight) and Kangaroo Mother Care (KMC)
method.
 To train participants to sensitise communities on prevention and control of other communica-

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 Guidance on Standardised Training of Community Health Workers
ble diseases (STIs, including HIV and AIDs; Tuberculosis (TB); Lassa fever and Yellow fever;
Onchocerciasis (oncho); Meningitis (neck stiffness);Worm infestations (including schistosomi-
asis); Anaemia and Skin infections).
 To train participants to deliver essential services to communities (Ivermectin for Oncho, con-
doms for STIs/HIV, de-worming tablets).
 To train participants to identify people with other communicable diseases and refer them ap-
propriately.
 Sensitize community health workers on neglected diseases within the context of Sierra
Leone
Time: 6 hours
Module overview
 Acute Respiratory Infection
 Oral Rehydration Therapy and Zinc for Diarrhoea management
 Malaria in under five year children.
 Severe Acute Malnutrition
 Low birth weight
 Malaria prevention and control-1 hour
 Long Lasting Insecticide Treated Mosquito Nets (LLITNs) – 1
 hour
 An overview of Community Case Management for malaria using ACT- children, pregnant
women, adults (refer to CIMNC for details)-1 hour.
 STIs, including HIV and AIDs
 Tuberculosis (TB)
 Lassa fever and Yellow fever
 Onchocerciasis (oncho)
 Worm infestations (including schistosomiasis)
 Anaemia
 Skin infections
 Malaria, ARI, Diarrhoea (see the other modules)
Materials
Counselling cards, Posters, Dolls, Towel/blanket, MUAC tapes, Under-five cards, Flip charts and
markers, Sample antibiotics, ACT, ORS and Zinc
Handouts
CHWs manual, Counselling cards, Posters, MUAC tapes
Preparation
 All materials needed for the training are available.

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 Guidance on Standardised Training of Community Health Workers

 Identify cases of acute malnutrition in advance to explain clearly to the CHW.

 Identify easily accessible mosquito breeding grounds (stagnant water, containers holding wa-
ter, clogged drains).
 Assemble training materials
 Ivermectin, de-worming tablets, condoms, wooden penis, sample of TB and HIV treatment,
 Reporting tools for oncho, de-worming, condoms etc.
Outcome of the module
 CHW can identify acute malnutrition and refer to the appropriate facilities for treatment, con-
duct defaulter tracing for malnutrition and carry out home visits.
 CHWs can identify LBW and train mothers/care givers on Kangaroo Mother Care (KMC).
 CHW can identify general danger signs and refer under five children to the appropriate health
facilities for treatment.
 Undertake FREE Community Case Management for Malaria, Pneumonia and Diarrhoea.
 Other communicable diseases
 Neglected diseases
 Information Education and Communication (IEC)
 Mobilize communities to drain stagnant waters, remove water receptacles and clear
bushes around residential places.
 Mobilize households on correct and consistent use of LLITNs.
 Identification of danger signs and referral
 Early identification of fever presentations and refer to PHU in cases where fever is ac-
companied with danger signs for further diagnosis and treatment.
 Early identification of non response to malaria treatment and refer to PHU for review.
 Provision of service
 Administer ACT to fever presentation at community level.
 Provide Directly Observed Treatment (DOTs) for SP for pregnant women.
 Participants are able to sensitise communities on prevention and control of other communi-
cable diseases (STIs, including HIV and AIDs, Tuberculosis (TB), Lassa fever and Yellow
fever, Onchocerciasis (oncho), Worm infestations (including schistosomiasis and anaemia),
Skin infections).
 Participants are able to identify people with other communicable diseases and refer them ap-
propriately
 Participants are able to deliver essential services to communities (Ivermectin for oncho, con-
doms for STIs/HIV, de-worming tablets).
 Increased awareness among community health workers of other communicable diseases
and neglected diseases.

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 Guidance on Standardised Training of Community Health Workers

Module 7: Adolescent Sexual and Reproductive Health Rights

Introduction
Adolescence  refers  to  the  period  of  a  young  person’s  life  between  the  ages  of  10  and  19.    During  
this transition to adulthood, adolescents develop biologically and psychologically and move to-
wards independence. Because adolescents encounter health risks and often exhibit risk-taking
and experimental behavior, counselors and care providers need to understand the stages of ado-
lescence and to be able to help adolescents attain a desired state of general and reproductive
health. It is also important for service providers to acknowledge the reproductive rights of adoles-
cents as a key foundation for service provision.
Objectives
To help providers understand the importance of adolescent reproductive health, the stages of
adolescent development, the desired state of general and reproductive health, and the reproduc-
tive rights of adolescents
Time: 4 hours
Module overview
 Nature of adolescence
 Adolescent vulnerabilities, risk taking behaviours and consequences
 Communicating with adolescents
 Safer sex and protection for adolescents
 Available adolescent friendly reproductive health services
Materials
Counselling cards; posters; flip charts and markers
Handouts
CHWs manual, Counselling cards and posters.
Preparation
 All materials needed for the training are available.
Identify cases of acute malnutrition in advance to explain clearly to the CHW.
Outcome of the module
By the end of the module, participants will be able to:
1. Explain the rationale for undergoing special training on adolescent reproductive
2. health.
3. Identify biological and psychosocial changes that occur during adolescence.
4. Discuss desirable health status for adolescents.
5. Identify the reproductive rights of adolescents.

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 Guidance on Standardised Training of Community Health Workers

Module 8: Sexual and Gender Based Violence

Introduction:
This module will provide community health workers with the necessary survivor-centered skills
and tools to improve referral systems and care and support to survivors of GBV in their communi-
ties. It will also help them understand key concepts related to GBV and apply basic engagement
skills that promote the safety and well-being of survivors.
Objective:
 To introduce participants to basic concepts related to working with survivors, including gen-
der, GBV, and multi-sectoral programming;
 To review possible bio-psycho-social  consequences  of  violence  and  survivors’  related  needs;;
 To provide all participants with practical methods for communicating with survivors that in-
crease survivor comfort and facilitate survivor coping skills.
 To provide all participants a thorough understanding of the dynamics and the physical and
psychosocial consequences of sexual violence. To provide all participants the tools to use in
survivor-centered skills when engaging with survivors, including with child-survivors.
 To practice survivor-centered skills in context-specific roles.
 To provide all participants with information on the different roles and responsibilities of all ac-
tors engaging with survivors of sexual violence.
 To provide information about protection activities and justice mechanisms involving survivors
of sexual violence.
Time: 2 days
Module Overview:
 Review of basic concepts related to GBV
 Nature and scope of GBV
 Understanding of how GBV affects individuals, families and communities
 Discussion on consequences of GBV for children
 Review of multi-sectoral and multi-level models for addressing GBV
 Overview of survivor-centered communication skills
 Review of basic information about psychological needs of survivors
 Review of key issues related to engaging with survivors
 Basic techniques for interacting with survivors
 Introduction to and practice with the Gather Model
 Understanding your goals and roles
 Practicing survivor-centered communication skills

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 Guidance on Standardised Training of Community Health Workers

 Self-care for participants

 Introduction to the medical modules
 Discussion on the role of CHWs
 Explaining care and obtaining consent
 Psychosocial support and treatment for survivors
 Care of the child survivor
Materials:
Flip charts, Projector, laptop, Name tags, Coloured markers, Coloured paper - A4 size, Plain
white paper - A4 size, note cards (small size) in various colours , A4 size note pads, pens, tape,
highlighter pens, sticky note pads, handouts for all participants.
Preparations:
Ensure all required materials and handouts are available and enough.
Outcome:
By the end of this module, participants will be expected to be able to practically apply the knowl-
edge and skills acquired and to have a survivor-centered attitude towards the survivors of sexual
violence they meet in their communities.
Knowledge
 Demonstrate a comprehensive understanding of the dynamics of sexual violence.
 Identify the consequences of sexual violence for the survivor, his/her family and community.
 Understand the importance of guiding principles for helping survivors of sexual violence and
of the related survivor-centered skills.
 Identify the various roles and responsibilities needed to support survivors of sexual violence.
 Understand the goals and limitations of protection work involving survivors of sexual vio-
lence
 Have a basic understanding of international human rights provisions relating to gender-
based crimes, including sexual violence; identify national legal and justice mechanisms and
services to protect and provide remedy to survivors; and implications for interviewing and
referring survivors.
 Demonstrate components of the assessment and evaluation of women, girls and boys who
experience sexual violence.
Attitude
To develop a survivor-centered attitude towards survivors of sexual violence.
Skills
 Be able to demonstrate a survivor-centered attitude and use survivor-centered skills when
engaging with survivors. This includes:
 ensuring the safety of the survivor

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 Guidance on Standardised Training of Community Health Workers

 ensuring confidentiality
 respecting the wishes, needs and capacities of the survivor
 treating the survivor with dignity
 adopting a supporting attitude
 providing information and managing expectations
 ensuring referral and accompaniment
 treating every survivor in a dignified way, independent of her/his background, race,
ethnicity or the circumstances of the incident(s).
 Be able to fully apply the rules around confidentiality

 Be able to ask for consent of survivors

 Be able to understand, discuss and inform survivors about available services while re-
specting  the  survivors’  right  to  choose
 Be able to apply survivor-centered skills with children

 Recognize the potentially stress-inducing impact of dealing with survivors of sexual vio-
lence and practice self-care strategies.
A summary of the programme with an indicative timing is shown in the table below.

Proposed 10 days training agenda for CHWs

Timing 8.30am-10.30am Tea Break 11.00am-1pm Lunch 2pm-4pm
Week 1 2 hours 2 hours 2 hours
Monday Opening/ Module 1 Module 2
Introductions- Pre-test
Module 1
Tuesday Module 2 Module 2 Module 2
Wednesday Module 3 Module 3 Module 3
Thursday Module 4-include Module 4 Module 4
adolescents
Friday Module 5 Module 5 Module 5
Week 2 2 hours 2 hours 2 hours
Monday Module 6 Module 6 Module 6
Tuesday Module 6 Module 6 Module 6
Wednesday Module 6 Module 6 Module 7
Thursday Module 7 Module 7 Module 8
Friday Module 8 Module 8 Post test-CLOSURE,
Award of certificates

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