"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
Background and Rationale
Community health worker (CHW) programmes are complex entities, operating at the interface of the formal health system, households and communities, and involving a wide array of actors and relationships. The advent of the Millennium Development Goals saw a mushrooming of often poorly coordinated, disease-specific (HIV, TB, maternal-child health) initiatives involving CHWs, leading to fragmentation, duplication and competition at country and community level. In the era of the Sustainable Development Goals, international guidance1 and country programs are promoting integrated national CHW programs supported by government health systems.
There is considerable guidance available on the tasks of CHW programmes, support systems required2 (e.g. supply chains, information systems, supervision), tools (e.g. m-health) and now costs3, but little on how to ensure overall coherence in CHW programme designs, structures and implementation processes appropriate to the context and at scale.
If CHW programmes are to achieve their potential, they need to be appropriately governed, a function referred to by the World Health Organization (WHO) as “overseeing and guiding the whole health system, private as well as public, to protect the public interest.”4 In broad terms, governance requires distributing roles, responsibilities and accountabilities amongst actors in order to achieve programme goals. Responsibility for the governance of CHW programmes lies primarily (although not exclusively) with government, and is required at all levels of the health system. For example, it is as important for a health ministry to achieve consensus on the place of CHWs in the overall national health workforce strategy, as for a district manager to ensure coordination and synergy of initiatives in their own district.
Based on research on the real-life tasks and challenges faced by policy-makers and managers in taking CHW programmes to scale, and drawing on conceptual and empirical literature on governance,5 this brief presents a framework structured around a set of key questions to ask in assessing the governance of CHW programmes.
The framework outlines the governance function of CHW programmes at all levels of the health system, and can be used:
1. As a basis for identifying gaps and needs for governance strengthening and support,
2. As inputs into curriculum design for training, or
3. To develop a tool to assess/monitor CHW programmes.
The framework is based on empirical observations from case studies and experiences of community-based health services in South Africa, where CHWs are organised into outreach teams as part of the country’s primary health care system. The observations straddled the design, adoption and implementation phases of the “Ward Based Primary Health Care Outreach Team” strategy at national, provincial and district levels over a number of years.6 In an inductive process of analysis, the governance tasks and challenges arising from the observations were identified and synthesized into five key domains (presented as the ‘key questions’ in Table 1).
The development of the framework was further informed by the following principles:
- CHW programme governance involves state and non-state actors, including non-governmental, community, provider and international actors;
- CHW programmes require a variety of modes of governance. Hierarchical approaches involving formal accountabilities have to be balanced with non-hierarchical relationships and capacity for collaborative (or network) governance across interest groups and stakeholders;
- Governance straddles all phases of the policy process: agenda setting, programme design, implementation and evaluation;
- As indicated earlier, governance tasks are distributed across the system, from national to local/district. Capacity for governance at district or local level becomes particularly important when national stewardship is weak;
- Effective governance requires a combination of analytic, managerial, technical and political roles and capabilities, supported by enabling systems, and political, budgetary and bureaucratic commitment.
Table 1 presents the framework. The foundational questions are organized into five overarching questions, broken down into 20 specific questions, and an additional cross-cutting question (“where does main responsibility for the function lie?”) to be asked with each of the others.
Table 1: CHW Programme Governance Framework
The first set of questions (“Is the programme appropriately designed for the national and local context?”) concerns the design of a CHW programme and the degree to which this reflects an imposed or negotiated vision across key interfaces - the global to the national, and the national to sub-national spheres. The questions look both backwards and forwards – backwards in finding the fit between international evidence and prior national and sub-national histories, needs and strategies; and forwards in assessing organisational capacity, actor readiness and public acceptance for change. With respect to programme ownership and identity, specific additional questions would include:
- Are CHWs conceptualised as agents of community mobilisation or as an extension of the health system?
- Are they civil servants and considered as part of the health workforce or be managed through non-governmental intermediaries (or both)?
- Are CHW programmes principally implementers of a core package of technical disease interventions or do they have a broader household and community role?
- Who are workers accountable to and who do they identify with – communities or the health system?
In the second set of questions (“Are local relationships optimally configured?”) frontline organisational and accountability relationships are addressed, highlighting the importance of programme structures that balance coordination and integration with the formal primary health care system with some degree of autonomy on the part of CHWs. This is necessary to ensure that CHWs do not become lowly players at the bottom of a health worker hierarchy, drawn into health facilities as an “extra pair of hands.”
The third set (“Are support systems in place, aligned with each other and functioning optimally?”) covers the key managerial and technical support systems – planning, priority setting, human resource (including training, remuneration and supervision), supplies, referral and monitoring and evaluation. These support systems need to be aligned with each other and ideally integrated with the primary health care system.
The fourth set of questions (“Is there appropriate leadership of change enabling learning and development over time?”) focuses on strategic roles such as building common visions and appropriate change-management/implementation strategies. This would include, for example, piloting, implementation task teams and creating feedback loops for learning by doing.
The final set (“Is there sustained political and budgetary support?”) relates to strategies that build wider commitment and support, including well-evaluated local experiments, the monitoring (and regular reporting) of impacts at scale, and the capacity of programmes to navigate politically.
Depending on the specific context, responsibility for each of the governance functions will lie at different levels/actors – whether at national, provincial/state or district levels of government – or with NGOs or partners.
Audience and Use
The framework has relevance for public-sector managers at national, provincial (or state) and district levels who are involved in designing, reforming or implementing CHW programmes; or who are required to play oversight and steering roles in ensuring coherence and synergy of community-based initiatives. It may also assist non-governmental organisations (NGOs), donors, international agencies and training institutions to reflect on how best to engage and support CHW programmes within countries. Finally, researchers and programme evaluators can draw on the framework to ensure that governance dimensions are adequately assessed.
Author Affiliation: University of the Western Cape, Cape Town, South Africa
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1. World Health Organization. WHO guideline on health policy and system support to optimize community health worker programmes. Geneva: World Health Organization; 2018.
2. World Health Organization. WHO guideline on health policy and system support to optimize community health worker programmes. Geneva: World Health Organization; 2018.
3. See the CHW Central Features: The Community Health Planning and Costing Tool (CHPCT) and Delivering Digital Education Content for CHWs on a Global Scale.
4. World Health Organization. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. Geneva, Switzerland: World Health Organization; 2007.
5. Schneider H. The Governance of National Community Health Worker Programmes in Low- and Middle-Income Countries: An Empirically Based Framework of Governance Principles, Purposes and Tasks. International Journal of Health Policy and Management. 2019; 8(1):18-27.
6. Schneider H, Nxumalo N. Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa. Int J Equity Health. 2017;16:72.