Poor management has often been cited as a common weakness in the sustainability of CHW programs. This is compounded by a lack of flexibility in management personnel to respond to contextual issues, poor training of managers, and a significant dearth of information on day-to-day performance of dynamic programs.
When a manager is strategic and has access to information about the operational and functional status of a program, it is more likely that a system will survive in a constantly changing environment.
Lessons learned from a number of global CHW programs have allowed us to identify methods to strengthen daily operational management of large, often remotely managed CHW programs. Tools such as the USAID- supported Assessment and Improvement Matrix also enable current day project managers to conduct systematic analyses of a complex CHW program’s various components. Furthermore, emerging technologies in mHealth provide additional opportunities for collecting information to guide decision-making and program management.
Using Information to Drive Management
Real-time data collection to assess CHW performance and health outcomes
In the Millennium Villages the mHealth platform ChildCount+ (www.childcount.org
) enables CHWs to collect to collect real-time data using SMS.
Information collected at the household level by CHWs using mobile phones can assist managers in assessing day-to-day CHW performance, household health outcomes, and community heath status. Reports can be generated from this information with indicators such as household coverage (i.e. - % households visited in the quarter), quality of care (i.e. - % children with RDT+ who received anti-malaria), vital statistics tracking (i.e. - % of expected births that were reported by CHWs) – each of these can be used by an individual CHW, by all CHWs, or by villages. A successful ChildCount+ system allows a manager to assess and address not only the health performance of villages, but also individual CHW performance in conducting visits and in quality of care.
Yet, to be effective, managers need to incorporate use of information on a regular basis. Helpful strategies to facilitate this are appropriate training in data usage, and the design of summative, intuitive and readable reports.
Qualitative performance assessments through community engagement
Quality information can bring in community perspectives or the “voice of the client.” In the Millennium Villages, we are currently developing a spot-check methodology whereby CHW supervisors (a community-based middle-tier of management) periodically visit randomly selected households to interview them on their experiences and interactions with the CHWs. A strong relationship with village health committees also adds an important layer of community input. In some countries, we have also begun to introduce “community dialogue days” to engage community members in some of the data trends observed, and to solicit community feedback on health programs.
Use of the CHW Assessment and Improvement Matrix (CHW AIM) for program assessment
In addition to individual performance assessment, it is also important to ensure that managers have an understanding of how the overall CHW system is performing. The CHW AIM tool has been used in the Millennium Villages as an annual assessment for the status of essential CHW program components such as recruitment, supervision, training, and performance evaluation. This process involved collecting numerous stakeholders – CHWs, facility-based workers, CHW supervisors, and CHW managers – to participate in two-day workshops to self-assess the program’s functionality in 15 system components. This process was pivotal in helping local project managers to systematically assess the status of their program and use this information to target specific components for improvement.
More information on the CHW AIM tool can be found here
Questions for discussion:
1. What are the most useful data for a CHW program manager to have at a village level? At a district level? At a national level?
2. How can one design a report dashboard to be dynamic and engaging to project managers on the ground?
3. What successful methods have been observed in use of data by local or regional CHW program managers to improve CHW programs?
4. What comprehensive information systems have other organizations implemented to help improve day-to-day management and decision making?
Anne Liu, MS, MSPH, is the Health Systems Development Coordinator at the Earth Institute's Center for Global Health and Economic Development at Columbia University. Her focus is on the strengthening of primary health care in the Millennium Villages through the integration of Community Health Worker (CHW) sub-systems with clinic-based Quality of Care initiatives. This includes supporting the implementation of the CHW Program, CQI projects for maternal and neonatal health in clinics, and overall health systems strengthening from a systems management perspective.
Continuing the Conversation...
Using the CHW AIM for program assessment: Millennium Villages Project in Rwanda
In Rwanda, the Mayange sector’s CHW program has 140 CHWs providing three different services: treating malaria, pneumonia and diarrhea; providing neonatal and pregnancy care; and registering births and deaths and counseling the community for behavior change. The CHWs are volunteers as dictated by government policy. They visit households daily and report collected data to the Millennium Village Project (MVP) for health improvement.
It is a big challenge to manage 140 CHWs that work daily, unpaid, with different roles but on the other hand this policy has an advantage when it comes to sustainability and scalability of our program. It puts limits on what can be implemented considering government resources and economy that could easily, with available resources, be scaled up and sustained if found effective.
The USAID Health Care Improvement (HCI) Project developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM) toolkit to help organizations assess CHW program functionality and improve program performance. MVP is devoted to achieving the MDGs in Rwanda’s Mayange sector despite the limited resources and infrastructure. To that end, MVP organized a two-day workshop to assess its CHW program with the help of the CHW AIM toolkit. The 15 participants in this workshop CHWs, program managers, government representatives and stakeholders related to Mayange CHWs.
Challenges and Benefits
Although the language was challenging to some, the workshop was an opportunity for us to work together, to evaluate ourselves and to take actions for change. This process demonstrated that we had similar ways of thinking and managing CHWs. We learned that small things that we thought were unimportant actually had a negative impact on the advancement of our programs. For example, we discovered that different organizations were working separately toward the same aim, sometimes using conflicting resources and energy. We realized there is a simple way this energy could be focused on the same purpose. Also, we found that the communities, which are direct beneficiaries of CHW activities, were not being considered.
Improvement actions identified during the workshop included increasing awareness of CHW activities through community meetings, discussing policy gaps with the MOH, collaborating with different organizations for CHW development, improving CHW evaluation, and increasing community involvement in CHW evaluations. Participants were assigned different tasks with time frames for completion. With set indicators we will know if we realized our tasks and achieved our targets. For instance, to improve evaluations, we introduced new evaluation criteria which will help us provide individual performance incentives; whereas before, incentives were provided to four CHWs as a group. This has recently started and active CHWs are very happy with this change.
In conclusion, we can say that this tool has contributed to an action plan that we hope will bring change in our program. The workshop attendees appreciated its outcome and recommended it take place twice each year. The toolkit was also presented to the health district manager who hopes to use it in other sectors such as Bugesera.
- What strategies do you use to make CHW programs more effective and efficient?
- What advice could you give to help us have the government scale up our effective programs?
Maurice Kwizera is the CHW Manager at Millennium Promise/ Millennium Villages Project for the Mayange cluster in Rwanda. He has been working in this capacity for two years; implementing the MDGs in Mayange cluster through management and capacity building of CHWs. Prior to MVP he was the head of radiology in the Rwamagana district for four years where he initiated radiographers using ultrasound machines. Maurice Kwizera holds a bachelor’s degree in health institutions management.