You are on page 1of 22

Summary of Proceedings from the Community

Health Worker Forum


Washington, DC, November 12, 2014

Background
USAIDs flagship Maternal and Child Survival Program (MCSP) called this meeting in order to
inform its Community Health workplan activities so that they are complementary to other
USAID-supported activities. An executive summary of these proceedings is available at
http://www.mcsprogram.org/.
Co-Facilitators were Laura Raney, Sr. Knowledge Management Advisor, MCSP/Jhpiego &
Telesphore Kabore, Community Mobilization Advisor, MCSP/Save the Children
The Maternal and Child Survival Program, launched in June 2014, is a global, USAID
Cooperative Agreement to introduce and support high-impact health interventions with a focus
on 24 high-priority countries1 with the ultimate goal of ending preventable child and maternal
deaths (EPCMD) within a generation. The MCSP builds on the Maternal and Child Health
Integrated Program (MCHIP), and is focused on ensuring that all women, newborns and children
most in need have equitable access to quality health care services.
As one of many players in the field of Community Health, both in the USAID sphere and
globally, MCSP has a high interest in ensuring community health worker (CHW) efforts are
successful and sustainable at scale. This forum brought together 41 participants2 from over 20
organizations including program planners, technical advisors, implementers, researchers, donors,
and evaluatorsinvolved in CHW programming to contribute their thinking to three related
objectives: 1) Consider the context of needs for communication on CHW issues. In particular,
what information is needed in terms of CHW roles, trainings, credentials, and services; 2)
Review the CHW Reference Guide and consider the content, suggest amendments, and provide
suggestions for effective and creative dissemination of the guide; and 3) Take advantage of this
gathering to continue promoting shared knowledge and connections between various
organizations and efforts regarding CHW programming.

Summary of the Agenda


The day was divided into several sessions based on the objectives of the meeting. In the morning,
participatory exercises and a report out session enabled the group to explore what information
* USAID's high-priority countries are Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, Ghana, Haiti, India,
Indonesia, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nepal, Nigeria, Pakistan, Rwanda, Senegal, South Sudan,
Tanzania, Uganda, Yemen and Zambia.
2 See Appendix A for list of participants.
1

Summary of Proceedings from the Community Health Worker Forum

and communication needs exist amongst Global Alliances, ministries of health and NGOs, and
implementing partners regarding working with CHWs. The group also spent time during the
morning comparing the various popular definitions of what is a CHW. After lunch, participants
worked in small groups and reviewed the CHW Reference Guide providing suggestions for
amendments to the various chapters and ways the guide could be disseminated globally and
locally. The meeting closed with various participants providing updates on their work around
CHW programming. A copy of the agenda can be found as Appendix B of this document. Slight
deviations from the agenda occurred in order to gather other pertinent information and address
invitee interests. Following are summaries for each session.

Introduction
Presenters: Karen LeBan, Executive Director, CORE Group, & Eric Sarriot, MCSP Community
Health and Civil Society Engagement Team Leader
Karen and Eric opened the meeting by saying that over the years, CHWs have emerged as
critical human resources, able to extend health systems and basic services directly to
communities and households. In response, the global health community has recognized the need
to harmonize their actions in support of CHWs. Eric encouraged the forum invitees to share their
thinking and experiences of how CHWS can help expand health services, in-particular at the
community level. Karen followed by empathizing the need for evidence-based learning to be
shared between Global Alliances, Ministries of Health at the national and district-level, NGOs
and implementing partners and communities in order to improve community-based health
systems. Additionally, Karen thanked everyone for participating in a pre-meeting survey and
shared the results of who is working where in the 24 EPCMD Countries with Large Scale CHW
Program. See Appendix C for additional information. She also shared a list of CHW resources3,
as recommended by invitees to the CHW Forum.

The list of CHW resources can be found at: http://www.coregroup.org/storage/documents/chwresources.pdf


Summary of Proceedings from the Community Health Worker Forum

Part 1. Information and Communication Needs


about CHW Issues
Co-Facilitators: Laura Raney, Sr. Knowledge Management Advisor, MCSP/Jhpiego &
Telesphore Kabore, Community Mobilization Advisor, MCSP/Save the Children
1. Community-level Communication Needs
As a way to allow the group to maximize their face-to-face time and provide a process to
gather thoughts, participants were asked to write their response on an index card to the
following question: What is the key information need or communication gap for
communities with regard to CHW programs? Following, each participant exchanged their
card with a partner and scored the idea in terms of how they felt about the idea (1 5, 1 being
a good idea and 5 being the best idea.) The participants were instructed to keep
switching cards with random partners until each idea had been scored by five people. The
scores for each card were then tallied. Thematic analysis of all the cards indicated that:

Communities need a clear idea of the roles and responsibilities of CHWs as well as what
the role of the community is in supporting CHWs.

Communities need better data on CHW performance in order to make informed decisions
regarding CHW programs.

Below are the top scoring ideas (ideas that received a score between 22- 25).

Communities need to know what and how much training CHWs receive. What tools
CHWs have to manage illness? How will they treat sick children? (25)

What are CHWs capable of and trained to do? When can they treat and when do they
have to refer people to the formal health system? Communities need to have a clear idea
on roles and responsibilities of CHWs so that there are not unrealistic expectations.(25)

Whats in it for me? What benefits will my community get from CHWs? (23)

Can CHWs help with issues other than health? (23)

Communities need to know what is expected of the community in regards to supporting


CHWs.(22)

Afterwards, participants were asked to repeat the exercise in two of three smaller groups of their
choice. Each small group had a moderator that asked the participants to answer a specific
question by writing their idea on a card. Following, each participant exchanged their card with a
partner and scored the idea in terms of how they felt about the idea (1 5, 1 being a good idea
and 5 being the best idea.) The participants were instructed to keep switching cards with
random partners until each idea had been scored by four people. The scores for each card were
then tallied.

Summary of Proceedings from the Community Health Worker Forum

2. Global Alliance Communication Needs


What is the key information need or communication gap with regard to CHW programs from
the point of view of Global Alliances? Top ideas from the Global Alliance group (ideas that
received a score between 15 -20) included:

Need to clarify the definition of CHWs roles and capacity. (19)

Need to facilitate sharing knowledge and experience so as not to duplicate efforts and
waste time. (18)

Need to know the principles of well-functioning CHW programs. (16)

Need to know how CHW programs can help to achieve coverage and linkages between
prevention and curative interventions. (16)

Need alignment and sharing of best practices and design considerations for CHW
programs by country. (16)

3. Ministry of Health Communication Needs


What is the key information need or communication gap with regard to CHW programs from
the point of view of ministries of health at the central level? Top ideas from the MOH group
(ideas that received a score between 15 -20) included:

The MOH needs to know where communities access services so that they can plan
support accordingly. (19)

Need to know how many functioning CHWs there are, who operates them, and where
they are located. (19)

What benefits CHWs bring to the system and how a CHW program costs to run. (18)

Need to know what a reasonable workload is for a CHW and the number of tasks that a
single CHW can deliver. (17)

How project financed and specialty trained CHWs fit into a sustainable and organized
district community workforce. (16)

How the CHW programs assist and promote the efforts of the MOH. (16) District folks
need to be better equipped with participatory methods and tools for a meaningful
community engagement.(15)

What types of CHWs are being supported in the districts, what their roles are, who is
supporting them, who is training them, what training they receive. (15)

How much a CHW program will cost. (15)

4. NGOs and Implementing Partners Information Needs


What is the key information need or communication gap with regard to CHW programs from
the point of view of NGOs and implementing partners? Top ideas from the
NGO/implementing partner group (ideas that received a score between 15 -20) included:

What are others doing so efforts can complement, not duplicate? (19)

What role does the MOH intend to play? (19)

Need to know and support the MOHs vision for CHW contribution to health
outcomes.(18)
Summary of Proceedings from the Community Health Worker Forum

Gaps in access and coverage.(18)

What benefits, compensation, training is being provided by others? (18)

What is the scope of work of CHWs and how they fit into the overall health system? (18)

What the MOHs standards and guidelines for CHW programs and NGOs and IPs are to
report data to the MOH? (17)
-

How to effectively work within a National CHW framework and contribute knowledge
learned through a NGO program to the larger system? (17)
NGOs and IPs need to know the national landscape- including policies and work by others, to
prevent overlap and conflicting messages. (16)

Sustainability of CHW programs. (15)

Availability of donor funding for CHW programs. (15)

5. Main themes across all three questions


After the small group work, the larger group came back together to discuss the results of
mornings activities. Laura started the conversation by asking, What knowledge and
experiences do we really have in terms of effective tools, benefits, training, cost benefits, and
consensus on roles and responsibilities of CHWs? What strategies do we have to fix the
communication gaps and integrate CHWs into the health system? The larger group
discussed several of the themes that came up during the morning activities including:

Need clarification on the definition of CHWs (roles, responsibilities, training)

Would like to see harmonization with ministries of health and also with other NGOs/
Implementing Partners on CHW programming

There needs to be a landscape of CHW programs at the country-level including national


policies and guidelines and performance and cost of existing/past programs

The need for a CHW landscaping and coordination in every community

What have we learned about how CHW programs can be sustained

What would a framework that integrates CHWs into a national health system look like
given that every context is different

What to do about the weak data on community health

How to structure community health systems in countries and how to rationally divide
tasks among all the key stakeholders.

Summary of Proceedings from the Community Health Worker Forum

6. Definition of a CHW
Currently there is a lack of consensus around a common definition of a CHW. Admittedly,
this is an incredibly complex area due to the large variety of community health workers and
volunteers. Nevertheless, there are several definitions that are currently being debated,
including the definition by the International Labour Organization4 that is currently being
promoted by the Frontline Health Workers Coalition5 and the definitions that appear in the
guide by Henry Perry et al.6 Nevertheless, coming to consensus seems very challenging.
While some groups are promoting a simplified definition, some organizations such as the
Global Health Workforce Alliance (GHWA) are interested in defining the difference between
CHW and community health volunteer (CHV). This session ended with a question posed to
the audience, How do you take a disparate group and work towards consensus?
Diana Frymus from USAID suggested one possible method that might help in reaching
consensus on a common definition is by using a modified-Delphi process.
In 2011 the USAID Health Care Improvement Project facilitated a modified Delphi approach
to identify, refine and build consensus on practice recommendations to improve in-service
training.7

Impromptu CHW Definition SessionSmall Groups with Report Out


As there was much debate around the definition of a CHW, the facilitators decided to have the
larger group break into smaller groups and compare the various definitions and also come up
with ideas on possible ways for the global community to come to consensus on a common
definition. After small group discussions, each table gave a summary of their discussion.
Highlights from the small groups are as follows:

Community health workers provide health education and referrals for a wide range of services, and provide support and
assistance to communities, families and individual with preventative health measures and gaining access to appropriate curative
health and social services. They create a bridge between providers of health, social and community services and communities
that may have difficulty in accessing these services. This definition provided by the International Labour Office. Found in:
International standard classification of occupations (ISCO-08). Volume 1. Structure, group definitions, and correspondence
tables. Geneva: ILO
5 The new report by the Frontline Health Worker Coalition, A commitment to community health workers: Improving data for
decision making makes four recommendations, 1) Those working with CHWs should come to consensus and use a common
definition for CHWs; 2) Guidelines should be created for a minimum core set of CHW data indicators (currently unavailable)
to better track and make decisions regarding CHW numbers, training, placement, outputs, and outcomes; 3) CHWs need to be
integrated into the public health system and; 4) Partners should build upon the harmonization framework. This report was
presented at the third Global Symposium on Health Systems Research in Cape Town, South Africa in October 2014 to great
reception.
6 Specifically, four types of CHW cadre are referred to throughout the CHW Reference Guide: 1) Auxiliary Health Workers
(AHW), who are paid, generally full-time workers with pre-service training usually of at least 1824 months, who may or may
not be recruited from the localities where they serve.; 2) Health Extension Workers (HEW) are usually paid, full-time
employees but have less than a year of initial training and are generally recruited from the localities where they work; 3)
Community Health Volunteers-Regular (CHV-R) generally work several hours a week, are non-salaried but receive some
material incentives, and have a role that can involve health promotion and some limited elements of service delivery; and 4)
Community Health Volunteers-Intermittent (CHV-I) whose duties normally involve only intermittent health promotion or
community mobilization. In H. Perry & L. Crigler (Eds.). Developing and Strengthening Community Health Worker Programs at
Scale: A Reference Guide and Case Studies for Program Managers and Policy Makers. Washington, DC: United States Agency for
International Development.
7 Between June and December 2011, the USAID Health Care Improvement Project (HCI) facilitated a global process that
engaged training program providers, professional and regulatory bodies, ministries of health, development partners, donors and
experts to develop and reach consensus on a set of practice recommendations to improve in-service training effectiveness,
efficiency and sustainability. For more information see:
https://www.usaidassist.org/sites/assist/files/inservicetraining_july2013.11x17spreads.pdf
4

Summary of Proceedings from the Community Health Worker Forum

Group 1 suggested that maybe a common definition is not needed because everyone has been
working with CHWs for so long. However, if there was to be a common definition, then perhaps
level of training and pay would be most useful and best criteria for categorization. Peter Winch
came up with S3I1C2P4 to talk about different categories. (S = skill level; I = incentive; C =
curative care; P = preventative care).
Group 2 started by questioning the number of definitions and suggested the need for a mapping
to be done. They concluded that all definitions are country-specific. They also suggested that
maybe the CHW definition problem is a symptom of a bigger problem. (Maybe issues within
health systems have caused this?) They also asked whose job is it to bring together the diversity
and richness of all the partners.
Group 3 stated that there is benefit in having categories and a consensus on a common
definition, both in terms of being able to count CHWs, as well as to tailor research questions
(such as incentives, training, supervision), around specific types of CHWs. Currently, research is
generic, whether a CHW is a full-time paid government worker or a part-time volunteer. Group 3
also suggested that the WHO and other convening organizations need to be in charge of
consensus building around a common definition and that a larger group of stakeholders, in
particular stakeholders from the country-level, need to be involved with developing the common
definition.
Key Highlights on Definition of CHWs:

In terms of a definition, it is important to decipher between paid and unpaid and trained and
less trained CHWs. It is hard to make recommendations without making that distinction.

Lets map out all potential categorizations of CHWs worldwide! This would be useful for
government communication and strengthening data systems by having more info on different
cadres.

Global mapping has been done with over 35 categories of CHW and has probably led to
overlap in roles.

Having salary info will help ministries of health. The info would also have a huge impact on
scale-up plans.

We need context-specific information. Our definitions need to be flexible for country


variation.

Definitions force us to think about which particular kind of CHW works best in which
situation. This is critical. There is not much data beyond a few case studies and there is no
way to compare efficacy between different kinds of CHWs.

There is a tendency in ICCM for health workers to focus on treatment and not on
prevention. This requires a different set of skills.

Terminology consensus is so important. Do we even have that consensus for the definition
of nurse? There is a pushback from the nursing community when CHW presence grows
unless there is a career path attached to their work. A career path cant be implicit; lets
enumerate what it is.

Lets have a harmonized framework for how CHWs are incentivized and supported.

Summary of Proceedings from the Community Health Worker Forum

Summary of Proceedings from the Community Health Worker Forum

Part 2: Structured Review of the CHW


Reference Guide
Henry Perry started the afternoon session out by providing a brief overview of the CHW
Reference Guide including a description of the intent of the Guide and how it was developed.
The idea for the guide came from Stephen Hodgins, who at the time was the Technical Director
for the MCHIP program. Figure 1 provides an overview of the milestones reached in the process
of developing the Guide. The Guide aims to make up for the lack of comprehensive views and
analyses of CHW programs from a global perspective and even from a national perspective.
Overall the goal of the Reference Guide is to:
1. To aid countries as they discuss, plan and implement activities to begin, expand, or
strengthen large-scale CHW programs
2. To provide a sounding board for issues that need to be considered
3. To emphasize the need to tailor national programs to the national context and to tailor local
implementation to the local context there is no one size that fits all!
Figure 1. Progression of the Guides development

Formation of team and


securing of some funds
Planning began in the
summer of 2011
Formation of key writing
team
Support for Henry
Perrys time and student
research assistance
through MCHIP
Key informant interviews

Fall 2013: near final


draft completed
USAID comments
received (extensive)
Comments at CORE
Group fall meeting
obtained
December 2013
public comment sought

March 2014
comments incorporated
New chapter added
(Chapter 6.
Coordination and
Partnerships for CHW
Initiatives)
New country case
studies added
(Indonesia, Zambia,
Zimbabwe, FWA and
HA programs in
Bangladesh)
Important resources
(Appendix) added
June 2014 official
launch

After Henrys presentation, the participants were asked to break into four small groups, each
representing one section of the CHW Reference Guide.

Policy and Planning

Human Resources

Summary of Proceedings from the Community Health Worker Forum

Health Systems and Community Relations

Measurement and Sustainability

Each small group was asked to answer three questions on their chosen section.

Do you agree with the content? Do you have any amendments?

What are the priorities of what should be disseminated?

What is the best way to disseminate the information? (Link with Global Alliances, ministries
of health at the district-level and NGOs and implementing partners)

Following are summaries of what was discussed and reported out by each small group.

1. CHW Reference Guide: Policy and Planning


Q1: Amendments to content

Chapter 6 Explanation of harmonization of partners could be clearer. For instance, how


would donors go about doing this?

Chapter 5 (financing) could be developed further. Maybe include finance and insurance
schemes. There needs to be more work in communities around the world regarding insurance
schemes.

Q2: Priorities for dissemination

The content of the Guide is currently not digestible for policy makers as it could be. It
seems to be written more for academics (kind of like a text book). USAID looking for easier
ways to have discussions with ministries of health regarding CHW programming. Perhaps if
the information in the guides were a bit more interactive it would make it easier to use. The
WHO is now using an interactive tool for health workers.

Consider developing different tools for different levels of government. For instance, the text
might want to target national and district levels as they have different powers.

Some ideas on how to make the guide more user friendly include:

Build on reference guide using language that is common

Include visuals

Make an online version that is interactive. For instance, where you could ask a question and
get a diagnostic response like using interactive voice response that leads you step-by-step
with prompts. Or you could develop algorithms where you link the type of problem with type
of country (e.g., size, epidemiologic profile, geography, and finance and government
structure).

Create a capacity building tool that consultants and staff can use to help guide countries.
Alternatively, the guide could include decision trees.

Wiki A forum that could support peer comparison / benchmarking

Could try and link this guide with the ASSIST tool from URC. However, their tool is
incompatible with this guide because it focuses primarily on smaller systems of volunteers

10

Summary of Proceedings from the Community Health Worker Forum

rather than large-scale national CHW programs; nevertheless, the tool does have practical
tools and is easy to access. (Note that the ASSIST tool has not been approved by USAID.)

Q3: Optimal ways to disseminate the guide

Guide authors could contribute to policy papers for USAID and WHO and make suggestions
as to how the Guide could apply

Wiki where individuals could post how they are using the guide.

Facebook page

Review the current GHWA/WHO eight thematic working group papers and comment on
them based on key recommendations in this report

Reach out to African MOH meeting to present or offer side session, promote at other relevant
global and regional conferences

Host webinars with key MOH reps from country case studies to disseminate concrete
guidance

2. CHW Reference Guide: Human Resources


Q1: Amendments to content
1. Appreciate condensed version of the Guide and case studies!

Revisit the four categories of definitions of CHWs as there seems to be some overlap

Include section on how to collect data and add a linkage to suggested tasks and training

Emphasis phasing in of skills in training to build competence, they may have on-going
continuing training

Add section on how to deal with community participation vs. elite selection of CHWs

Include section on urban vs. rural recruitment and incentives

Ch7: No mention of reporting linkage for CHWs, are they responsible to anyone?
-

This is probably included in the data chapter but should be here to as it is a task needs to be
trained on and takes time to complete during workday

No mention of 2-way referral mechanism between health facility back to CHW

Talk about preventative care and treatment in beginning of Ch7, but then do not explicitly
mention that in Ch9need to highlight continuum of care in Ch9

Regarding four categories of CHW roles (Table 1, Ch 7)


-

Are these the right categories of task and should there be more explanation about overlap of
roles?
Is FP contraception covered under preventative section? What about injectables?

CHWs tend to supervise volunteers -- > this is not mentioned in the tasks explicitly

Appreciation for discussion of tasks and when /where performed as well as discussion of
generalist vs. specialist. But should there also be mention of social support of two CHWs
working together in the same geographic regions

Summary of Proceedings from the Community Health Worker Forum

11

Liked the observation of more than just level of education is important. Whole context
within which CHW will be working is important in determining what level of education
is necessary.

Supervision
-

Couldnt CHWs get together and have a dialogue about whats been challenging (There is a
larger section on peer supervision, in the expanded chapter)
Workers tend to be more mobile than the supervisors (more willingness to come meet peers);
not the same as going out to the community to observe. Reverse supervision

Task shifting between CHW and volunteer a lot of preventive counseling things can be
shifted

Good harmonized communication materials needed to be used by CHWs and volunteers

Phased approach to training is highlighted in the chapter. There are linkages to CHW
motivation.

Suggestion to include a table to organize what skills or what tasks could be considered
for a CHW program
-

When are you going to max out on skills?


Very large evaluation of Pakistan LHWs: higher basic education, continuous supply of
commodities, and supervision by trained supervisor link to higher performance by CHWs

Recruitment: says best practice to CHW recruitment by community but does this ever
happen in practice at large scale?

It is usually by elite capture or village council?

Suggestion to include more about how selection decisions actually made? There is a lot
of political connections happening in the selection

Very little evidence of people being from the community as an important factor in
strong CHW programs; but there is evidence that should be from a rural area

A lot of large countries now investing in urban health workers to deal with slums.
-

12

Gets at the ratio question. Put people in setting where working with peers. This also helps
with retention.

Urban context may be require different incentive structures, different recruitment strategies
etc.

Summary of Proceedings from the Community Health Worker Forum

Q2: Priorities for dissemination


Community

Knowing what to expect: What are roles and tasks of CHWs

Any costs expected to be incurred by community

How are CHWs serving my community?

Who would make a good CHW?

How do they recruit, select, etc.?

Community mostly needs picture/posters (this is the how of dissemination)

Responsibilities of community

CHW

CHWs, themselves need to understand roles/tasks, recruitment, incentives, responsibilities at


a deeper level. Perhaps design a handbook or flipchart that explains the contents of
handbook.

Knowing roles and tasks, expectations

NGO

Local context

Existing incentive structures; harmonization with other programs and with MOH programs

Role of NGO in sharing the CHW reference guide or pieces of it with the DHMTs or
regional hubs

MOH

Key tables it isnt easy to get people to go through long documents

Infographics smaller/flashier!

Briefs on key topics of interest (incentives, roles, training, supervision)

Should there be a distinct dissemination strategy with professional councils?

Global Alliance

Read the whole document!

Q3: Optimal ways to disseminate the guide

Share easily digestible information in the guide with communities so they understand
roles/tasks, recruitment, incentives, responsibilities. Best done through community-led
discussion, posters, etc.

Disseminate small sections of the guide at district management meetings

Disseminate through professional organizations. Important because doctors and nurses are
often afraid of job overlap with CHWs

Summary of Proceedings from the Community Health Worker Forum

13

MOH may be particularly interested in supervision methodology tables and charts as info
package.

2. CHW Reference Guide: Health Systems and Communities


Q1: Amendments to content

Add the recent Human Resources for Health journal article addressing use of logic model8 to
the Guide

Add section on power. Are CHWs in or out of national health system? What does it mean to
be in or out? Discussion of power and power sharing. Whether CHWs are linked to HS or
communities. Example of power: Benin: how decentralized/centralized and battles in terms
of who makes decisions in terms of management systems.

The guide is a large document and while the condensed version is a step in the right
direction, it may still be too dense. Perhaps consider adding visuals.

Perhaps add an interactive CHW decision-making tool to help decision-makers think through
their context

Questioned whether community engagement should be moved up in the order of chapters. A


CHW program that works must be linked to community. You need community buy-in, as
well as national resources.

This is a textbook, we need something like the CHW AIM toolkit, provide guidance for
exercises in planning, recognizing the profile of the country, asking the right questions.

Q2: Priorities for dissemination

How to work through power sharing issues- centralized, decentralized and communities vs.
national

Q3: Optimal ways to disseminate the guide

Regional state-of-the art trainings (SOTAs) sponsored by USAID

Democracy and governance BBLS at USAID. Eric Sarriot says that USAID has spoken
with folks, and they are interested. Want them to come to MCSP to link work/discuss

HS Global meeting in Vancouver

E-trainings

The Guide has already been disseminated via GHWA through their listserv
www.healthsystemsglobal.org and HSG in the article Supporting and strengthening the role
of CHWs in health systems development.

3. CHW Reference Guide: Measurement and Impact


Naimoli, J. F., Frymus, D. E., Wuliji, T., Franco, L. M., & Newsome, M. H. (2014). A Community Health Worker logic model:
towards a theory of enhanced performance in low-and middle-income countries. Human resources for health, 12(1), 56. Available
at: http://www.human-resources-health.com/content/12/1/56
8

14

Summary of Proceedings from the Community Health Worker Forum

Q1: Amendments to content

Case studies/ concrete examples very helpful. Perhaps go through the whole document and
link the information in the chapters to specific case studies.

Would like to see more information/ data/ case studies on the following topics:

numeracy skills in countries

Platforms for data collection (i.e., using mobile technology)

Indicators on coverage and quality

How to use data at the local level to improve services

baseline assessment

How to track the caseload of CHWs

How to create a health info system that is user friendly

Q2: Priorities for dissemination

How to measure: quality and coverage

How to share negative results for use as opportunity to discuss solutions

How to use this information to improve services

Q3: Optimal ways to disseminate the guide


1. Identifying champions within each country
2. Storytellers as advocates who have relationships with wide variety of partners; share cases in
an exciting and innovating ways
3. Taking MOH partners to different countries to observe successful programs in other places
4. Internet e-version!

Summary of Proceedings from the Community Health Worker Forum

15

Part 3. Country Case Studies


During this session, Henry Perry provided a brief presentation on the case studies that are
included in the CHW Reference Guide. In all, there are 121 pages of the most complete and
extensive description of large-scale CHW programs currently available. There are also several
failed programs featured (e.g., Indias Village Health Guides and Zimbabwes CHW Program).
The case studies were compiled by students at Johns Hopkins University and use a consistent
format that includes the following:

Summary

Historical context

Countrys health needs

Existing health infrastructure

Program description

Communitys role

Selection, training and incentives of CHWs

Supervision

Program financing

Demonstrated impact and continuing challenges

After Henrys presentation, copies of the condensed case studies were provided and a large
group brainstorming session was facilitated by Telesphore. Three topics were discussed:

Dissemination of the case studies

How they can be used in the future

Ideas to keep building on them

In terms of dissemination of the case studies, participants suggested:

Creating a wiki with entries by country and topical areas where those involved with CHW
programming can add information and leave comments.

The participants stated they foresee using the case studies as a learning tool and hope in the
future that some of the case studies will include infographics so that they easy to understand
are even more compelling.

Participants also suggested the case studies could be improved by adding an analysis section
before the description and including a policy and planning section that provides a brief
introduction of the governance structure of each country and the results of any policy work
that has happened in conjunction with the CHW programming.

Part 4. Partners and Global Updates


Brief Summaries
16

Summary of Proceedings from the Community Health Worker Forum

There are new publications on CHWs and Ebola at http://www.chwcentral.org

USAID is committed to addressing fragmentation issues around CHW programs at both the
country and global level. ASSIST is conducting CHW case studies in several countries.
Additionally, USAID Child Survival and Health Grants Program is completing operations
research on community health programming in several countries that will result in briefs
disseminated by MCSP. USAID is also working with WHO and World Bank on a human
resources for health strategy to help ensure universal health coverage. More at:
https://www.usaidassist.org/blog/why-universal-health-coverage-depends-human-resourceshealth

The One Million CHW Campaign has created a virtual inventory of CHW programs in subSaharan Africa. The new Data Exploration Tool maps CHW programs and displays
information on the current state of CHW operation submitted by governments, civil society
organizations and other CHW program implementers and partners. So far over 1000 CHW
programs have registered on their site at: http://1millionhealthworkers.org/operations-room

KIT Health, together with Queen Margaret University and the Liverpool School of Tropical
Medicine conducted research on the cost-effectiveness of community health workers in lowand middle income countries. A copy of the paper can be downloaded at:
http://www.kit.nl/health/kit-news/community-health-workers-cost-effective

Advancing Partners and Communities has developed a Community Health Systems


Catalog, an innovative and interactive reference tool on country community health systems.
The Catalog covers USAID priority countries and is intended for ministries of health,
program managers, researchers, and donors interested in learning more about the current state
of community health systems. More at: http://www.advancingpartners.org/resources/chsc

The Gates Foundation have been doing work around CHW programming in Ethiopia/
Malawi/ Rwanda/Burkina Faso. Earlier this year Gates approved a strategy sub-initiative for
CHWs. Some of the issues they are planning to focus on

Support to governments to ensure they are able to play stewardship role for national
scaled programs

Using data to improve performance of CHWs

Leveraging existing tools

There is a focus on countries with the most child deaths: Nigeria, India, Ethiopia

Summary of Proceedings from the Community Health Worker Forum

17

During the fall 2014 CORE Group Global Health Practitioner Conference participants
explored the role of NGOs in strengthening health systems, from a primary health care
perspective that includes community systems, with a focus on supporting CHWs. CORE
Group is publishing a paper based on the fall conference titled, Strengthening Community
Health Systems through CHWs and mHealth tools. Additionally, CORE has created two
CHW-related taskforces. The first one aims to develop an assessment tool based on the CHW
Program Functionality Matrix in the CHW AIM toolkit. Once finished, the adapted tool will
be able to be used to review the functionality of community health groups against 15
practices. Each of the 15 components will be subdivided into four levels of functionality to
enable organizations to match their current status against a continuum of responses to guide
their assessment. The second taskforce will focus on developing a framework for linking
community to the health system.

To date, Phase I Global Fund investments in malaria control and health systems
strengthening (HSS) have played an important role in supporting the iCCM platform in
various countries. Phase II funding is now available and will assist countries that have had
their concept paper approved in grant making.

IntraHealth International has been providing pre-service training to nurses in Tanzania and
Zambia to help strengthen their link with CHWs and the community.

The MOH of Ethiopia is seeking donor support for cross visits with other ministries of
health to help facilitate learning on how to strengthen primary health care.

There are three working papers on CHWs on the GHWA website

18

Framework for partners harmonized support

Monitoring and accountability

Collation of knowledge gaps through systematic reviews and from USAID evidence
summit in 2012

Summary of Proceedings from the Community Health Worker Forum

Appendix A: Participant List


Name
Julia Bluestone

Organization
Jhpiego, FHWC

E-mail
julia.bluestone@jhpiego.org

Sarah Borger

Food for the Hungry

sborger@fh.org

Angela Brasington

Save the Children

abrasington@savechildren.org

Mary Carnell

JSI

mary_carnell@jsi.com

Megan Christensen
Elizabeth Creel

Concern Worldwide US
John Snow Inc.

megan.christensen@concern.net
ecreel@jsi.com

Priya Emmart

Futures Group

pemmart@futuresinstitute.org

Kate Fatta

URC

kfatta@urc-CHS.COM

Alison Foster

IntraHealth International

afoster@intrahealth.org

Diana Frymus

USAID

dfrymus@usaid.gov

Lenette Golding

Maternal and Child Survival


Program (MCSP)
Independent Consultant

Juli Hedrick

World Vision

jhedrick@worldvision.org

Troy Jacobs

USAID

tjacobs@usaid.gov

Enric Jan

Bill & Melinda Gates Foundation enric.jane@gatesfoundation.org

Telesphore Kabore

Save the Children

Justine Kavle
Nazo Kureshy

PATH/MCSP
jkavle@path.org
USAID Bureau for Global Health nkureshy@usaid.gov

Karen LeBan

CORE Group

kleban@coregroupdc.org

Gayle Martin

World Bank

gmartin2@worldbank.org

David Milestone

USAID

dmilestone@usaid.gov

Tanvi Monga

MCSP/ICFI
Maternal & Child Survival
Program (ICF International)

tanvi.monga@icfi.com

Subarna Mukherjee

Health

smukherjee@tiyatienhealth.com.org

Ivy Mushamiri

One Million CHW Campaign

ivy.mushamiri@millenniumpromise.
org

Michel Pacqu

MCSP

michel_pacque@JSI.com

Tanvi Pandit

JSI/Advancing Partners and


Communities Project (USAID)

tanvi_pandit@jsi.com

Henry Perry
Sruti Ramadugu

John Hopkins University


MCSP/Jhpiego

hperry2@jhu.edu
sramadugu@mchip.net

Laura Raney

MCSP/Jhpiego

laura.raney@jhpiego.org

Jim Ricca

Jhpiego

Jim.Ricca@jhpiego.org

Anita Gibson

Melanie Morrow

agibson@mchip.net
lenette.golding@outlook.com

tkabore@savechildren.org

melanie.morrow@icfi.com

Summary of Proceedings from the Community Health Worker Forum

19

Kerry Ross

USAID

kross@usaid.gov

Eric Sarriot

ICFI

Eric.Sarriot@icfi.com

David Shanklin
Anne Siegle

CORE Group
ICFI/CEDARS

dshanklin@coregroupdc.org
anne.siegle@icfi.com

Deborah Sitrin

Save the Children

dsitrin@savechildren.org

Luis Tam

MSH

ltam@msh.org

Matthew Trevino

MCSP/Jhpiego

mtrevino@mchip.net

Charlotte Warren
Kate WilczynskaKetende

Population Council
UNICEF iCCM Financing Task
Team

cwarren@popcouncil.org

Peter Winch

Johns Hopkins Bloomberg School


pwinch@jhu.edu
of Public Health

20

kwketende@unicef.org

Summary of Proceedings from the Community Health Worker Forum

Appendix B: Agenda
9:00 9:15am

Introduction
Karen LeBan, Executive Director CORE Group
Eric Sarriot, MCSP Community Health and Civil Society Engagement Team
Leader

9:15 10:15am

Information and Communication Needs About CHW Issues


Small Groups

10:15 10:30am

Break

10:30 11:30am

Review of Small Groups and Discussion

11:30am 1:00pm

Lunch & Gallery Walk

1:00 2:30pm

Structured Review of CHW Reference Guide by Main Themes


Dissemination Opportunities
Small Group Exercise

2:30 2:45

Break

2:45 3:30pm

Report Outs and Discussion

3:30 4:00

Country Case Studies

4:00 4:45pm

Partners and Global Updates


TBD

4:45 5:00pm

Closing Remarks
Karen LeBan, Executive Director CORE Group
Eric Sarriot, MCSP Community Health and Civil Society Engagement Team
Leader

Summary of Proceedings from the Community Health Worker Forum

21

Appendix C: Preliminary Results of the Pre-CHW Forum


Survey Monkey

22

Summary of Proceedings from the Community Health Worker Forum