MCHIP Publishes Document on Community Health Worker Programs at Scale

7 May 2014

MCHIP is pleased to announce the publication of "Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policy Makers." This document is an in-depth review of issues and questions that should be considered when addressing key issues relevant for large-scale CHW programs.

To download the Guide in its entirety, click here.

Rather than being an instructional manual, the Reference Guide is meant to provide a framework for those in leadership positions in-country as they consider how to develop, expand and strengthen their CHW program. It was developed in parallel with the URC/Project ASSIST CHW Decision-Making Support Tool, which is also in the process of being released.

The Reference Guide has many practical examples from CHW programs around the world. The contents are in four sections and contain a total of 16 chapters covering such topics as a history of CHW programs, planning, governance and financing, national coordination and partnerships, roles and tasks, recruitment, training, supervision, motivation and incentives, relations with the community and health systems, scaling up, and measurement and data use. There is an appendix containing (1) case studies from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia and Zimbabwe; (2) a summary of perspectives on large-scale CHW programs from key informants; and (3) important resources.

To download PDFs of each chapter, refer to the links below:

Section 1: Setting the Stage
Chapter 1. Introduction
  • The current enthusiasm for large-scale Community Health Workers (CHWs) needs to be tempered with a sobering reflection on the disappointments that followed a similar wave of enthusiasm in the 1970s and 1980s, noting challenges in scaling up and sustaining large-scale public sector CHW programs.
  • Large-scale public sector CHW programs are complex entities that require adapting a systems perspective to the national and local contexts.
  • CHWs are a diverse group of community-level workers. This guide distinguishes between two levels of CHWs: (1) full-time, paid, with formal pre-service training and (2) volunteer, part-time workers.
  • The guide attempts to avoid categorical recommendations, but rather offers suggested issues and principles to consider and, when possible, brings in relevant program experience.
Chapter 2. A Brief History of CHW Programs
  • The first Community Health Workers (CHWs) were “Farmer Scholars’’ who were trained in China in the 1930s and were the forerunners of the Barefoot Doctors, of whom there were more than one million from the 1950s to the 1970s.
  • In the 1960s and 1970s, small CHW programs began to emerge in various countries, particularly in Latin America.
  • The experience from CHW programs predating the 1970s provided the inspiration for much larger CHW programs in many low-income countries in the 1980s.
  • Following the failure of many of the programs in the 1980s and 1990s, new highly successful programs have emerged. As a result of research findings demonstrating the effectiveness of community-based programs in improving child health in particular, there is now a resurgence of interest in and growth of CHW programs around the world.
Chapter 3. National Planning for Community Health Worker Programs
  • The planning process defines many of the other topics in this manual (e.g., supervision, training, roles and responsibilities of Community Health Workers [CHWs]) using an informed and methodical process.
  • The most effective planning mechanism is a feedback loop, where community-level information is fed through the multiple sublevels (e.g., district, subnational, or provincial) to the national level, where policy, funding, and evaluation can be continually revised.
  • Careful planning during the design and implementation of a national CHW program results in a context-appropriate program that successfully trains, supervises, and retains CHWs, while simultaneously improving health service delivery on the community level.
Chapter 4. Governing Large-scale Community Health Worker Programs
This chapter discusses the following key questions that decision-makers need to consider in relation to governing CHW programs:
  • How, and where within political structures, are policies made for CHW programs?
  • Who, and at what levels of government, implements decisions regarding CHW programs?
  • What laws and regulations are needed to support the program?
  • How should the program be adapted across different settings or groups within the country or region?
Chapter 5. The Financing of Large-scale Community Health Worker Programs
  • Proper costing of a community health worker (CHW) program and assurance that those costs can be paid for on a sustainable basis are essential for an effective large-scale CHW program.
  • Failure to do so has led to the demise of large-scale CHW programs in the 1980s.
  • Direct and indirect costs of CHW programs need to be estimated, along with investment and recurring costs, in order to adequate plan for the sustainable financing of a CHW program.
  • CHW program costs vary widely from country to country as a result of contextual factors, such as local labor costs, whether CHWs are paid or voluntary, and the degree to which the program is well-supervised with a strong logistics systems.
  • Governments, local communities, and external donors are the main sources of financing for CHW programs.
Chapter 6. Coordination and Partnerships for Community Health Worker Initiatives
  • Community health workers (CHWs), unlike other formal human resources for health (HRH) cadres, have diverse links with the formal health system in many countries. They are also positioned within a complex array of relationships in the social setting of the communities where they work.
  • The complex and diverse challenges of CHW initiatives that emerge in a number of countries are invariably beyond the power of a single actor to address and require coordination and collaboration among different players and actors at all levels.
  • The multisectoral coordination of HRH, including CHWs, is not an objective in its own right; it is a means to an end, while the end objective is universal health coverage (UHC), achievement of Millennium Development Goals (MDGs), and elimination of health disparities within the country.
  • The multisectoral dimensions of CHW initiatives demand a multisectoral policy process and a coordination mechanism that can provide an environment and a platform where the related sectors can work together to harmonize and synchronize their efforts.
  • There are several national multipartner coordination mechanisms for health; however, the coordination process for CHW initiatives, as well as for other aspects of HRH, should be able to meet the country’s needs, and should be aligned with other coordination mechanisms as part of the overall health agenda.
  • Synergy and harmonization of financial and technical support from international actors in response to the national needs is vital for CHW initiatives to contribute to UHC and ensure equitable access to the essential health services within that country. A framework for harmonized actions and a joint commitment on CHWs provide appropriate opportunities to synchronize partners’ actions in support of CHWs initiatives.
Section 2: Human Resources
Chapter 7. Community Health Worker Roles and Tasks
  • A number of health care services exist that can make a significant difference to maternal and child health (MCH) in poor settings. Because community health workers (CHWs) are close to communities, both geographically and socially, they could potentially be responsible for a number of these services.
  • When planning new CHW roles or expanding the roles of existing CHWs, program planners need to analyze current research evidence and evidence-based guidelines on the effectiveness and safety of relevant tasks performed by CHWs. Planners need to assess whether the recommended CHW roles and tasks are considered acceptable and appropriate by their target population, by the CHWs themselves and by those who support them. Finally, planners need to think about the practical and organizational implications of each task for their particular setting with regard to training requirements, health systems support, work location, workload, and program costs.
  • This chapter provides a list of questions that may help program planners think about important issues when determining CHW roles and tasks.
Chapter 8. Recruitment of Community Health Workers
  • Developing appropriate recruitment policies and processes is a critical feature of an effective large-scale community health worker (CHW) program.
  • Community engagement in recruitment is highly desirable, but managing this in a way that is productive requires careful planning and adaptation.
  • An effective recruitment program can help reduce attrition, which is a major challenge for many large-scale CHW programs.
Chapter 9. Training Community Health Workers for Large-Scale Community-Based Health Care Programs
  • CHW training needs to be carefully adapted to the needs of the trainees, the job, and the tasks they are expected to perform and the context in which they will be working.
  • Current training approaches and techniques that are effective for training CHWs should be employed.
  • Examples of training programs and their structures from a variety of CHW programs are provided.
Chapter 10. Supervision of Community Health Workers
  • Supervision for community health workers (CHWs) is one of the most challenging program elements to implement; yet, it is considered one of the most important elements to successful programs.
  • Supervisory responsibilities have changed over time from providing administrative and clinical oversight to the inclusion of psychosocial support to frontline CHWs who face a wide range of challenges on their own.
  • Supervision is generally considered to be oversight from a health worker at a peripheral facility; however, this model is costly and difficult to implement. Alternative approaches might include group supervision, peer supervision, and community supervision to distribute the supervision tasks and increase support to CHWs in some contexts.
Chapter 11. What Motivates Community Health Workers? Designing Programs that Incentivize Community Health Worker Performance and Retention
  • Financial compensation is one – but only one – of many influences on the motivations of community health workers (CHWs) to perform their responsibilities.
  • Non-material incentives need to be given careful consideration along with financial incentives.
  • Indirect non-material incentives, such as the degree to which the environment is supportive of CHWs and the degree to which the health system functions effectively are also motivating influences for CHWs.
  • Lack of appropriate incentives, with resulting high rates of turnover, are common in large-scale CHW program and costly in terms of actual cost to replace CHWs and also in terms of the performance of the CHW program.
Section 3: CHW Programs in Context
Chapter 12. Community Health Worker Relationships with Other Parts of the Health System
  • Well-designed, functional support and interaction between CHWs and health systems are essential for effective community health services.
  • Large-scale community health services often are delivered by health systems that are inherently weak, posing considerable design challenges. In general, for community health services to function well, adequately strong support systems are needed.
  • Community-based health services should be seen as the foundational first tier of the health system.
Chapter 13. Community Participation in Large-Scale Community Health Worker Programs
  • Balancing the inherent tensions of a large-scale community health worker (CHW) program, where the CHW is the lowest-tier worker of a national health system while also acting on behalf of the always-changing local world of a community, will be an ongoing challenge requiring decentralized flexibility in program policy, design, and implementation.
  • A successful CHW program requires the support and ownership of the community, as well as a supportive social and policy environment for community participation at national, district, and local levels.
  • Cost and time of the implementer, district, and national-level personnel should be factored in when designing a community participation strategy.
  • The development and support of community networks, linkages, partners, and coordination is necessary to enable a comprehensive community-participation approach for better health.
  • Village health committees and other local governance structures can be effective mechanisms to ensure local leadership, legitimacy, participation, and governance, but these committees require continued training and investment.
Section 4: Achieving Impact
Chapter 14. Scaling Up and Maintaining Effective Large-Scale Community Health Worker Programs
  • Effective programming at scale requires having a viable, scalable program that works on a small scale under routine field conditions, followed by careful planning (appropriate to the national context) that assures long-term sustainability at scale.
  • Ongoing monitoring and evaluation (M&E), with adjustments to the program based on these findings, is essential both for effective scale-up and long-term program effectiveness at scale.
  • Scaling up is a political process, so leadership and proper engagement with the political system, national-level stakeholders, and the Ministry of Health (MOH) is essential.
Chapter 15. Measurement and Data Use for Services Provided by Community Health Workers
  • Routine measurement and data use for community health services are poorly developed in most countries.
  • Such information systems, if well-developed and used, can strengthen community health services, including the performance of community health workers (CHWs).
  • Sometimes additional information will need to be collected beyond what is normally reported on routine monthly report forms.
  • Descriptions of some of the findings from monitoring and evaluation of large-scale CHW programs in Pakistan and India are provided.
Chapter 16. Wrap-Up
  • The current enthusiasm for large-scale Community Health Worker (CHW) programs needs to be tempered with a sobering reflection on the disappointments that followed a similar wave of enthusiasm in the 1970s and 1980s and that challenges in scaling up and sustaining large-scale public sector CHW programs remain.
  • Large-scale public sector CHW programs are complex entities that require adapting a systems perspective to the national and local contexts.
  • This reference guide has attempted to avoid categorical recommendations and has suggested issues and principles to consider and, when possible, has cited relevant program experience.
  • CHWs are not a stop-gap measure in a second-rate health program, but a permanent part of a highly functional and effective first-class health system.
Appendix A. Case Studies of Large-Scale Community Health Worker Programs
Examples from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe (Henry Perry, Rose Zulliger, Kerry Scott,
Dena Javadi, Jessica Gergen, Katharine Shelley, Lauren Crigler, Iain Aitken, Said Habib Arwal, Novia Afdhila, Yekoyesew Worku, Jon Rohde, and Zayna Chowdhury)

Appendix B. Current Perspectives on Large-Scale Community Health Worker Programs
Summary of Findings from Key Informant Opinions (Sharon Tsui, Elizabeth Salisbury-Afshar, Rose Zulliger, and Henry Perry)

Appendix C. Important Resources

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