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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

Dr. Ranu S. Dhillon

The CHW Reference Guide was produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project.

The overview provided in Chapter 3 National Planning for Community Health Worker Programs (Gergen, Perry and Crigler) closely mirrors my experience helping to design the Village Health Workers program in Nigeria, develop the plan for a national community health worker (CHW) program for Guinea, and strengthen the ASHA (Accredited Social Health Activist) program in different states of India.

Based on these experiences, there are several pragmatic insights that build on points articulated in the chapter:

Positioning the process
The impetus for planning a national CHW program can come from many directions and greatly influences who leads the process and how it plays out. Regardless of how the idea initially takes root, it is important for the process to be embedded as early on as possible within an agency that has the clout and positioning to carry it forward. Without this combination of authority and structure, it is very difficult for CHW programs to gain the traction they need and enter the mainstream policymaking discussions, particularly since they require additional budgetary allocations. Understanding the political economy unique to each country and situating the program with the right support and vehicle is crucial for its success.

Identifying a core group and key partner(s)
The process of conceptualizing, planning, and then rolling out a national CHW program can be daunting and requires collaboration with multiple partners in the health sector. In both Nigeria and Guinea, we formed a core group of top Ministry officials and global experts who could do the preliminary legwork for the program and structure the process by which stakeholders could contribute to its development. This approach ensured there was enough substance to guide initial discussions as well as a clear team to coordinate the process once stakeholders were engaged. It also ensured that early conversations did not become too diffuse and could be directed towards concrete decisions and action steps. For driving the overall process, though, it may be beneficial to identify and engage one or two key partners with particularly strong interest in seeing the program established who could support the government through the critical initial steps when a program can get stuck and die before it even gets started or set out on a misguided path that becomes difficult to redirect further down the line.

Thinking about decentralization
A crucial decision for national CHW programs is how different functions—setting policy, operational planning, financing, managing implementation, monitoring and evaluating—are organized across different levels of government. Deliberate consideration is needed in how overall planning and, ultimately, execution of these elements takes place at each level. This must be country specific based on political dynamics, existing administrative structures, and the distribution of capacity. Beyond planning, similar decisions about decentralizing discretion need to be thought through for other functions of the program, such as financing and monitoring and evaluation. It is important that these choices are carefully evaluated during the planning phase.

Calibrating the operational model
There are many examples of CHW programs, but it is essential that a national program be tailored to each country and locality. Rather than putting forward a generic model, each country’s CHW program should be matched to the exact needs and gaps of its health system and then adjusted to the capacity present at the local level. For example, in India there is tremendous variation across different states. Though there is a general policy for how ASHAs—the CHW cadre in India—should operate, the operational model must be adjusted to each state. In the state of Assam, for example, maternal and child health needs predominate and many of the women who are eligible to become ASHAs will not be literate. This differs from Punjab where cardiovascular disease and heroin are major health issues and many villages have high school and even college-educated women who could potentially become ASHAs. With this in mind, the model for what an ASHA does and how she operates within the broader health system should look very different in Assam than in Punjab. Rather than simply importing best practices from abroad or using a blanket one-size-fits-all approach, national programs should combine a nuanced understanding of the needs and the capacity of people who can be trained as CHWs to develop their model.

Specifying the details of training and management
The chapter underscores the need to plan how training and management will be carried out, and how a lack of attention on these features has been a pitfall for many programs. A strategy for these essential functions should be clearly spelled out during the planning process. As the chapter describes, these tasks are often levied onto primary health level professionals—many of whom have no skills or training as managers—to take on in addition to their regular work.

Planning the CHW program has to be as much about setting up essential support mechanisms as actually deploying the CHWs. Without dedicated resources and potentially even institutions to execute training, CHW programs, especially at national scale, are doomed to underperform. In the same way, managing CHWs in the field may be one of the most important ingredients for success and should be carefully planned out. Training for managers and tools to guide them in their supervisory role, as well as clear reporting protocols, need to be developed. If the importance and scope of these tasks are not taken into account during the formative planning stage, the program is bound to run into problems once planning shifts to implementation.

Iterating design and performance
n health, the mindset is usually to plan out the “ideal” approach based on available evidence and norms and then implement it with the assumption that performance will follow. This way of doing things needs to be reoriented to the way engineers approach problems—using best practices to frame an initial approach and then use real experience and data to replicate it—and be built into the planning and execution of national CHW programs. The chapter describes the idea of re-planning these programs every five to ten years. In practice, though, there need to be mechanisms for continual improvement on a tighter cycle, even quarterly, especially at the outset when a program is first introduced and likely to encounter several ‘bugs’ (i.e., training period needs to be made longer, managers need more support). CHW programs need to incorporate real-time information systems such as those that can be facilitated by mHealth tools to enable dynamic management that constantly reacts to feedback. In this regard, planning a national CHW program requires in-depth engagement with the country’s information systems so that CHWs’ actions on the ground and data on health systems can be built out synergistically.

Altogether, the authors provide a very clear and methodical process for building national CHW programs that resonates with my own experience. Paying close attention to the details—of political context, of what should be done at each level of the system, of what specific needs can CHWs really meet, of how training and management will happen, of how the program will refine its assumptions—is critical in the planning stages. If these details are not thought through carefully, it can be difficult to get the program the legs it needs to get started or lead to challenges that become more difficult to resolve once the program is already up and running.

dhillon_photo.jpg Ranu S. Dhillon is faculty in the Division of Global Health Equity at Brigham and Women’s Hospital and Harvard Medical School and a Senior Health Advisor with the Earth Institute at Columbia University. Dr. Dhillon has led initiatives to develop community-based primary health systems at the local level in Rwanda, district level in Liberia, and national level in Nigeria and India, including the Nigeria Village Health Workers program and Conditional Grants Scheme to Local Government Area initiative. He is currently based in Guinea where he serves as an advisor to the President of Guinea and the Guinean National Ebola Coordination Cell on the national Ebola response. Dr. Dhillon has served on expert panels with WHO and UNICEF and is currently co-convener of the Financial Access technical resource team of the UN Commission on Life-Saving Commodities for Women and Children.


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