National Guideline for Implementation of Integrated Community-Based Health Services

Objectives

Botswana’s guideline aims to guide and standardise integrated community-based health services, operationalising the 2017 Primary Health Care-Community Health Worker Coordination Strategy, strengthening primary health care, and advancing universal health coverage through people-centred, rights-based and sustainable care.[1][2][3]It positions community health workers as a core health-system workforce linking households, communities and facilities, particularly for underserved and vulnerable populations.[4][5]

• Deliver a standardised minimum package of integrated interventions, including HIV, tuberculosis, non-communicable diseases, reproductive, maternal, newborn, child and adolescent health, malaria, nutrition, mental health, rehabilitation, eye and hearing health, palliative care, substance misuse and healthy ageing.[6][5]
• Strengthen coordination, management, leadership and governance through harmonised community health worker groups and community participation structures.[1][2][7]
• Build community health worker competencies, skill mix, supervision and career development through training curricula, field guidance, mentorship and supportive supervision.[8][9]
• Improve information management, monitoring and evaluation through harmonised indicators, standardised tools, electronic reporting and routine data-quality assessment.[8][10]
• Shift health services from fragmented, disease-specific and predominantly curative programmes towards preventive, promotive, integrated and continuous care centred on individuals, families and communities.[6][11][12]
• Promote community ownership, service acceptability, feedback and accountability by involving communities in planning, decision-making, implementation, resource mobilisation, monitoring and evaluation.[2][3][13]
• Support epidemic preparedness and response, including COVID-19 prevention, education, surveillance, referral, contact tracing, quarantine support, stigma reduction and ethical practice.[12][14][15]

Implementation

Implementation uses an integrated primary health-care delivery model in which trained community health workers and volunteers provide services at household, individual, family and community levels, identify unmet needs, deliver education and preventive support, and link clients to health facilities and other services for continuity of care.[16][17][18]The national framework allows districts to adapt service packages, referral arrangements and task shifting to local disease patterns, service access and community needs through consultation with local structures and beneficiaries.[11]

• Organise the workforce into Community Health Worker I, II and III cadres and volunteers, differentiated by education, training and service scope.[19][9]Link lower cadres and volunteers to the formal health system through Community Health Worker I supervision and facility support.[19][20][21]
• Use structured and scheduled home visits, client screening, health education, counselling, peer communication, support groups, community campaigns, adherence support, household follow-up and referrals to deliver the minimum service package.[17][22][23]
• Maintain multidirectional referral networks connecting households, community workers, primary health-care facilities, district health offices, hospitals, private and civil-society providers, referral transport and specialist services.[19][24]
• Engage Village and Ward Health Committees, Village Development Committees, traditional Kgotla structures, Dikgosi, support groups, religious and community leaders, civil society organisations, community-based organisations and the private sector in planning, coordination and service uptake.[2][25][3]
• Coordinate district delivery through District Health Management Teams, supported by Community Health Nurses, Health Education Officers and Community Health Worker Coordination Teams; maintain national oversight through the Ministry of Health and Wellness Health Services Management Department and Community Health Services Advisor.[25]
• Develop quality standards, service protocols, standardised referral tools, memoranda of understanding and formal agreements with strategic stakeholders and community-based organisations.[26][7]
• Train workers through pre-service and in-service curricula, interactive workshops, practical scenarios, mentoring, coaching and supervisory visits, including COVID-19 modules on prevention, misinformation, stigma, outreach and legal and ethical responsibilities.[8][27][28]
• Apply occupational health, infection-prevention, confidentiality, waste-management, commodity-management and ethical procedures to protect workers, clients and communities.[29][30][15]
• Collect service data daily using standardised registers and tools; compile and verify reports monthly through senior community health workers, nurses-in-charge, facilities and district teams; and progressively establish electronic real-time reporting through District Health Information Software 2.[31][32][33][8]
• Monitor implementation through indicators covering stakeholder alignment, minimum-package delivery, referral completion, quality standards, functional coordination structures, worker training, reporting, electronic-system use and service expenditure.[26][7][34][10]
• Use data-quality checks, feedback, trend analysis, district comparison, remedial action plans, process evaluation, outcome evaluation and impact evaluation to support improvement and accountability.[31][32][35][36]

Monitoring & Evaluation

The guideline establishes a multi-level monitoring, evaluation and reporting approach for community-based health services, combining routine community data collection, facility and district oversight, national information management, community participation and accountability mechanisms.[31][32][8][10]

• Collect service and intervention data daily during client contacts using standardised tools, including individual registers, prescribed collection sheets and Daily Activity Sheets.[31][32][33]
• Submit community health worker reports monthly to senior community health workers, who compile reports within five days after month-end with community health workers and nurses-in-charge reviewing, correcting, cross-checking and signing the data.[33]
• Submit facility reports monthly to District Health Management Teams, and prepare quarterly Ministry of Health reports using monthly submissions.[33]
• Require the senior community health worker to coordinate collection, enter and verify register data, arrange independent second-person verification, resolve discrepancies, complete summaries and submit compiled monthly reports to the Community Health Nurse.[31]
• Require the Community Health Nurse to manage late, incomplete, inaccurate or missing reports, submit monthly and quarterly reports to the District Health Management Team Head, and provide resources and feedback for routine information management.[32]
• Assess data quality through weekly supervisory spot checks, register-to-summary comparisons, secure filing for verification and audit, monthly feedback on timeliness, completeness and accuracy, and data-quality audits.[31][32]
• Strengthen information management through harmonised indicators and data-collection tools, electronic reporting, routine data-quality assessments, programme reports and community-based surveys.[8][10]
• Develop an electronic reporting system linked to District Health Information Software 2 (DHIS2) to enable real-time reporting, improve reporting rates and strengthen data quality.[8]
• Monitor community health worker supplies, activities and performance to identify under-performing districts, target follow-up and inform performance-based incentives.[13][17]
• Track implementation through indicators covering stakeholder alignment, implementation and delivery of the standard minimum service package, standards and protocols, referral-tool use, functional coordination structures, memoranda of understanding and agreements with community-based organisations.[26][7]
• Monitor completed referrals, access to integrated services, annual community-based health expenditure and review of the community health worker scheme of service.[34]
• Apply targets of 100% stakeholder implementation and 100% service delivery according to the standard package; targets for referral completion and access remain to be confirmed or determined.[34]
• Conduct process evaluation by the end of year 2 through reports, focus groups, budget assessments and human-resource assessments, examining timeliness, delivery of expected outputs and efficient use of resources.[10]
• Conduct outcome evaluation through report reviews, focus groups, surveys and desk reviews of information management, worker competencies, and coordination, leadership and management.[36]
• Conduct end-term impact evaluation using surveys and document review to assess service delivery, leadership and governance, and community health worker literacy.[36]
• Involve communities in planning, implementation, monitoring, evaluation and definition of key performance indicators, using village-level monitoring linked to facilities and recognised local structures.[12][13]
• Support accountability through community forums, advocacy, feedback channels, supervisory structures and district reporting to district development committees and full councils.[25][20][37]
• Strengthen surveillance through community-level syndromic surveillance, outbreak preparedness, screening, contact tracing and monitoring of people self-isolating with mild COVID-19 symptoms.[5][14][38]

Costing & Financing

The guideline identifies financial, human and material resources as necessary inputs for community-based health services, community health worker development and monitoring and evaluation, but provides no monetary budget, allocation, funding gap, financing target or quantified economic assumption.[26][8][39]

• Plan and cost monitoring and evaluation activities, staffing, consultants, training, facilities, equipment, transport, maintenance, information systems, translation, printing, publication, capital costs and external evaluations, incorporating requirements and contingencies into programme budgets.[39]
• Use human and financial resources to implement the standardised minimum service package, harmonise community health worker groups, develop competencies and strengthen community-based health information management.[26][7][8]
• Track annual expenditure on community health services, community health worker remuneration, incentives and financial packages as part of the monitoring framework, without specifying values or allocations.[34]
• Facilitate budgetary support for establishing a community health worker cadre through the primary health care and community health worker coordination strategy.[3]
• Mobilise community material, financial and human resources through community-led partnerships to improve cost-effectiveness and sustainability.[13]
• Promote integrated service delivery as a means to reduce duplication, minimise resource waste and serve more people with similar or lower resource use.[5][25]
• Apply cost-effectiveness alongside feasibility and public acceptability when selecting technologies, policies and priorities.[12]
• Provide resources for information management, including standardised registers and summary forms, office supplies, filing systems, mobile phones, updated tables and reports, and indicator definitions.[32]
• Resource waste-management, commodity storage, transport and supply-chain arrangements for community health workers; implementing partners may support commodity availability through direct procurement.[30]
• Recognise that community health worker remuneration, incentives, career development, protective clothing and supportive working conditions affect workforce satisfaction and retention.[9]
• Provide workshop space and materials for COVID-19 training, including toolkits, presentation slides, flip charts, markers, hand-outs, charts, posters and leaflets.[27]
• Consider logistics, budget implications and sustainability when using SMS reminders for tuberculosis directly observed therapy, and provide supplies for home-based care where required.[40][21]