By: Dr. Henry Perry
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.
In response to the rapid increase in and expansion of community health worker (CHW) programs in low-income countries over the past decade, my colleagues and I are delighted to be able to share a valuable new resource for strengthening CHW programs at scale. This document, Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, is the product of 27 different collaborators who, collectively, have a formidable breadth and depth of experience and knowledge about CHW programming around the world. The document provides a thoughtful discussion about the structure and functions of large-scale CHW programs. Our goal is to assist planners, policy-makers, and program implementers in strengthening existing large-scale programs and in designing and scaling up new programs. This work was guided by a senior writing team composed of myself along with Lauren Crigler, Simon Lewin, Claire Glenton, Karen LeBan, and Steve Hodgins.
The CHW Reference Guide, as we refer to it, can be downloaded in its entirety of 468 pages or chapter by chapter. It contains chapters in four main sections: (1) Setting the Stage (the history of CHW programs, planning, governance, financing, and national coordination and partnerships), (2) Human Resources (roles and tasks, recruitment, training, supervision, and incentives), (3) CHW Programs in Context (relationships with other parts of the health system, and relationships with the community), and (4) Achieving Impact (scaling up and sustainability, and measurement and data use). An extensive Appendix contains case studies, perspectives from key informants, and a list of other important resources. There are case studies of national CHW programs in 12 different countries: Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. These case studies are the most complete descriptions of these national CHW programs that are currently available. A summary of interviews carried out by the writing team with experts with extensive experience working with large-scale CHW programs provides important insights into challenges that large-scale CHW programs face.
The CHW Reference Guide addresses issues and challenges that all large-scale CHW programs face, and it provides many examples of how specific programs have addressed these issues. It does not try to present simple (or single) solutions to these complex issues, but rather raises questions that need to be considered by policymakers and program implementers in their own particular context, along with possible options and resources for addressing these questions. The Guide does not address specific technical issues related to specific interventions (such as the types of interventions and services that CHWs can provide, the details of training and logistical support required for individual interventions, and so forth).
The increasing momentum for expanded and stronger CHW programs is a welcome development for so many of us who have long seen the potential for stronger community-based programs to improve the health of populations, and particularly to improve the health of mothers and children. There is growing evidence that impressive gains can be made in smaller populations with well-trained and well-supported CHWs implementing discrete interventions over a relative short period of time, including for health promotion and for the prevention and treatment of serious conditions that are leading causes of mortality.1 Furthermore, a substantial number of countries with strong, large-scale CHW programs have made remarkable progress in expanding the coverage of key maternal and child health interventions. These countries have shown impressive gains in reducing maternal and child mortality and in expanding the coverage of family planning services with concomitant reductions in fertility – for example, Bangladesh,2 Nepal,3 and Ethiopia.4, 5
The resurgence in CHW programming has been slow in coming. The initial upswing of enthusiasm and experience with large-scale CHW programs in the late 1970s and early 1980s was associated with their endorsement at the International Conference on Primary Health Care and in the Declaration of Alma Ata.6
- Perry HB, Zulliger R. “How Effective Are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerage Progress in Achieving the Health-Related Millennium Goals 2012,” Johns Hopkins Bloomberg School of Public Health, September 2012, http://www.coregroup.org/storage/Program_Learning/Community_Health_Workers/review%20of%20chw%20effectiveness%20for%20mdgs-sept2012.pdf (accessed January 26, 2015).
- El Arifeen S, Christou A, Reichenbach L, et al., “Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh,” Lancet (2013): 382(9909), 2012-26.
- Houston R, Acharya B, Poudel D, et al., “Early initiation of community-based programmes in Nepal: a historic reflection,” Journal of Nepal Health Research Council (2012): 10(21), 82-7.
- Banteyerga H., “Ethiopia’s health extension program: improving health through community involvement,” MEDICC review (2011): 13(3), 46-9.
- Olson DJ, Piller A., “Ethiopia: an emerging family planning success story,” Stud Fam Plann (2013): 44(4), 445-59.
- WHO, UNICEF, “Declaration of Alma-Ata: International Conference on Primary Health Care,” September 6-12, 1978. http://www.who.int/publications/almaata_declaration_en.pdf (accessed January 26, 2015).
|Henry Perry is a Senior Associate in the Health Systems Program of the Department of International Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Dr. Perry has a formal background in medicine (including general surgery), public health, sociology and anthropology; he conducts research on community-based primary health care.|