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Evaluation report

2017 Namibia: Evaluation of Namibia’s Community Health Extension Workers Programme



Author: UNICEF

Executive summary

 With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as ‘Part 3’.

Background:

In 2008 the Ministry of Health and Social Services (MOHSS) commissioned a national health and social service system review which found that although some progress has been made in primary health care, provision of health services did not go beyond the health facilities, irrespective of the vast distances between the Health facilities and community. The review then recommended that health services should be extended in a structured manner to communities through the establishment of paid health workers.

In 2012 the MoHSS piloted Community Health Workers programme, and following the successful pilot project in Opuwo, the MoHSS expanded the programme to the rest of the country. Namibia has been implementing the Community Health Workers Programme (CHWP) since 2012 with over 1600 CHWs. In the past five years the programme package expanded and advanced significantly, yet no comprehensive evaluation has been undertaken to assess the relevance, efficiency, effectiveness, impact and sustainability of the programme.

An evaluation was undertaken to guide the MoHSS on how to use the CHWs most effectively to achieve national health goals, and contribute to the achievement of the post-2015 global Sustainable Development Goals. Programmatic achievements and constraints need to be documented and analysed, informing new technical guidance to maximize the impact of the Community Health Worker Programme (CHWP). It is in this context that this comprehensive evaluation was commissioned by the MOHSS with the financial and technical support from UNICEF and USAID-MCSP.

Purpose/Objective:

The purpose of the evaluation was to document the CHWP, assessing programmatic achievements and constraints by reviewing the existing conceptual framework and overall system, including financial support, management structure, supervision mechanism and governance. The evaluation aimed to gain an in-depth understanding of the progress and challenges, and to identify areas for improvement; to assess the alignment with, and appropriateness of, policies and guidelines for the community health programme; as well as to determine the extent and depth of coordination and collaboration for partnerships. The findings of the evaluation will mainly be used by MoHSS and partners, in their different capacities and functions, to inform policies and strategies and develop future plans and interventions to improve programme performance. It could also be used in academic settings, especially public health and teaching on community health.

The overall goal of the evaluation was to understand whether the intended objectives of the CHWP were met and whether it resonates with the objectives in the strategic plan. The main objectives of the evaluation are to i) assess the impact, relevance, effectiveness, efficiency, coherence, sustainability, coordination, and human-rights based approach of the programme; ii) document lessons and identify best practices in the implementation and management of the Programme; and iii) provide evidence to improve the programme design and implementation, and related policy change.

Methodology:

The evaluation was guided by the norms and standards of the United Nations Evaluation Group (UNEG) given their systematically established relevance for evaluating initiatives and programmes. The evaluation examined the impact, relevance, effectiveness, efficiency, sustainability, and coordination of CHWP. It also examined human rights, gender and equity dimensions of the programme. Evaluation framework (EF), which identified indicators for each question, was developed in a participatory approach with the involvement of key stakeholders.

The evaluation used a mixed-method (qualitative and quantitative). The quantitative component focused on existing retrospective health facility data to analyse the trends in maternal, newborn and child health outcomes. The qualitative component used desk review of documents and interviews. Semi-structured interviews were used. The data collection method comprised a mix of site visits and observations, key informant interviews using semi structured questionnaires, community Focus Group Discussions using guiding questions, desk-based review of existing documents, reports and secondary health facility data.

For the purpose of the evaluation, 5 regions were purposively sampled. The regions include Zambezi (average performance), Kunene (poor performance and unique characteristics), Oshana (good performance), Omaheke (good performance) and Karas (poor performance). A total of 60 key informants and 6 FGDs were conducted.

Both quantitative and qualitative data were analysed. On the quantitative aspect, trend analyses on key MNCH outcome/impact indicators to compare the pre- and post-programme implementation trend. The qualitative component drew on the understanding and perception of the main stakeholders involved in the project. In addressing the questions of the evaluation, findings from the different sources were triangulated to present the final findings

Findings and Conclusions:

CHWP has contributed to the improvement of maternal, newborn and child health indicators.
CHWP contributed to improved health awareness and knowledge among the community.
CHWP’s contribution to increased access was limited to selected health services.
CHWP contributed to improved health seeking behavior and increased utilization of maternal, newborn and child health.
The Community Health Worker Programme fits well to National priorities.
The programme’s strategic documents and approaches were appropriate to achieve the set objectives but the design had some limitations.
CHWP has not yet contributed to major policy direction and decision making processes, but it has contributed to increased resource allocation for the maternal, newborn and child health.
The development process, and the quality and content of the training curriculum were found to be appropriate for the programme.
The current operation of the training process was found to be inefficient.
Coordination mechanisms involving steering committees have been established but functionality was inconsistent.
Programme supervision was not strong and differed between regions.
There was high political commitment and will at the highest level, however management capacity was not strengthened.

CHWP has contributed to improvements in the capacity of regions and districts to deliver community health workers services.
CHWP contributed to a moderate increase in the participation of community members in CHWP.
CHWP has increased motivation of community health workers.
CHWP has moderately improved coordination of community health services, but the inconsistent and non-systematic coordination resulted in duplication of efforts.
CHWP has established and strengthened community health facility bidirectional referral linkage.
The available resources were generally used efficiently; however there were gaps in human resources, finance and logistics.

Recommendations:

1: The Government needs to further strengthen its political commitment and stewardship role.
2: Develop detailed costed plan with annual breakdown through bottom up approach and strengthen programme monitoring.
3: Strengthen supportive supervision
4: Strengthen managerial capacity of districts to ensure regular planning and monitoring.
5: Improve the motivation and satisfaction of CHWs.
6: Further strengthen behavioral change communications to empower local communities.
7: Strengthen community engagement and participation to ensure community ownership.
8: Improve access to MNCH services to respond to the increased demand created by CHWP.
9: Strengthen the coordination mechanisms at all levels of the health system with clear ToR.
10: Improve the quality of HIS data and use the information for tracking progress and decision making.
11: Institutionalize the training of CHWs and develop an integrated refresher training module.
12: Strengthen advocacy
13: Establish cross-sectoral collaboration.



Full report in PDF

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Report information

Year:
2017

Country:
Namibia

Region:
ESAR

Type:
Evaluation

Theme:
Health

Partners:

Ministry of Health and Social service

Language:
English

Sequence:
2017/002

 

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