By: Madeleine Ballard and Rebecca Furth*
Rigorous studies — randomized control trials — indicate that community health workers can effectively deliver health services as diverse as birth control injections and HIV care management. They also show that CHWs can ultimately reduce child morbidity, child mortality and neonatal mortality. Yet studies on national CHW programs in Burkina Faso, Ethiopia, and Malawi found that CHWs did not reduce mortality, which means that CHWs sometimes fail to contribute to health impacts. But why is that?
When deployed on a national scale, CHWs are often insufficiently trained, equipped, supervised and paid. Too many health systems do not set CHWs up for success and, as a result, they under-perform and fall short of their potential. To close the healthcare access gap we must do things differently — not just with medical innovation, but with collaboration for better design, improved systems management, and strengthened financing and coordination of CHW programs.
Purpose and Objectives
To help organizations assess community health worker program functionality and improve program performance, Initiatives Inc. developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM) Toolkit in 2011 for the USAID Health Care Improvement (HCI) Project. Built around 15 core domains, the original CHW AIM toolkit was framed around two key resources: a Program Functionality Matrix – to assess the effectiveness of a CHW program’s design and implementation – and a Service Intervention Matrix – to determine how CHW service delivery aligns with program and national guidelines. The Program Functionality Matrix provides a framework for program assessment, with each of the domains divided into four performance levels from 1 (non-functional) to 4 (highly functional). By scoring each sub-domain, users create a picture of strengths and challenges in the program. Scores and repeat assessments can be used to monitor program development over time.
Since the launch of CHW AIM, investment in CHW-led health delivery has continued to grow and the body of evidence related to CHW effectiveness has also expanded considerably. In 2018, the Community Health Impact Coalition, USAID, UNICEF, and Initiatives Inc. came together to update the CHW AIM Program Functionality Matrix to reflect the most recent evidence and recommendations for effective CHW program design and management.
To update the criteria for each of the components, the latest reviews on CHW program efficacy and effectiveness, as well as syntheses of practitioner expertise, were consulted. To ensure comprehensiveness, a systematic search for tools intended to aid policymakers and/or practitioners in community health worker program and policy design and implementation was carried out. Over 200 documents were close-read for inclusion. Relevant tools identified were linked in the appropriate sections of the revised Program Functionality Matrix.
Revisions were vetted across multiple stakeholders (including funders, program implementers who applied previous versions of the toolkit, and policymakers) for accuracy and usability. Readers familiar with the original Program Functionality Matrix will find the following changes to the document:
- To enhance the usability of the tool, efforts to streamline the program components reduced the previous fifteen components to ten (Table 1). Several key elements were merged to simplify the domains.
- Criteria for CHW accreditation was added to the tool to reflect emerging best practice.
- Guidance on performance incentives, including the analysis of potential negative unintended consequences, was added.
- Additional recommendations for supply forecasting, such as the use of a standardized tool/and or process (such as the UNICEF/MSH Community Health Planning and Costing Tool) were included.
Table 1: Updated Program Functionality Matrix Domains
The updated Program Functionality Matrix can be applied at district, regional, and national levels to identify and close gaps in design and implementation and, ultimately, enhance program performance. As with the original AIM tool, this updated version is intended to support the processes of programmatic design, planning, management, assessment, and improvement, for stakeholders ranging from local NGOs, to national policymakers and planners, to district managers and global stakeholders (Figure 1).
Figure 1: CHW AIM Users and Uses
The tool can be used and assessment facilitated by anyone who is literate and committed to assessing their CHW program against best practice. Some experience with assessment and workshop facilitation is recommended. Guidance for using the tool, including facilitation of stakeholder workshops, scoring and action planning, is included in the original tool document and can be used with the updated matrix. The tool will help users to identify strengths, challenges, and actions to improve the program.
The CHW AIM tool has been used by stakeholders to support the drafting of national policy, design of local programs, assessment of program implementation, and planned improvement over time.
National governments in Kenya and Rwanda used the tool to strengthen their programs and support policy reviews. International NGOs such as Save the Children and World Vision International used the tool to evaluate programs. The WHO used the tool to conduct a desk review of country programs across regions. The CHW AIM tool has even supported cross-country learning, with Integrate Health using the tool to ask the question of what a community health program in the Bronx, USA could learn from one in Northern Togo (Figure 2).
Figure 2: The AIM tool used for cross-country learning (courtesy of Kevin Fiori and Integrate Health)
Across these use cases, organizations have reported using the findings to make targeted changes to their programs and strengthen their quality. Operations research conducted by Initiatives Inc. in Zambia demonstrated an association between CHW performance and CHW AIM scores, suggesting that programs that score higher on CHW AIM also have better performing CHWs (Citation).
Community health workers can help achieve universal healthcare, but only if they are set up for success. Try the tool yourself here!
Madeleine Ballard: Executive Director, Community Health Impact Coalition
Rebecca Furth: Senior Technical Advisor, Initiatives Inc.
Note on Authorship: Contributing authors to the the updated CHW AIM Program Functionality Matrix include the following. Community Health Impact Coalition: Madeleine Ballard, Matthew Bonds (PIVOT), Jodi-Ann Burey (Village Reach), Jennifer Foth (Living Goods), Kevin Fiori (Integrate), Isaac Holeman (Medic Mobile), Ari Johnson (Muso), Serah Malaba (Living Goods), Daniel Palazuelos (PIH), Mallika Raghavan (Last Mile Health), Ash Rogers (Lwala), and Ryan Schwarz (Possible). Initiatives Inc.: Rebecca Furth and Joyce Lyons (CHW Central). UNICEF: Hannah Sarah F. Dini and Jérôme Pfaffmann Zambruni. USAID: Troy Jacobs and Nazo Kureshy
1 Scott, K., S. W. Beckham, M. Gross, G. Pariyo, K. D. Rao, G. Cometto and H. B. Perry (2018). “What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers.” Hum Resour Health 16(1): 39.
2 Hazel, E., J. Bryce and t. I.-J. i. E. W. Group (2016). “On Bathwater, Babies, and Designing Programs for Impact: Evaluations of the Integrated Community Case Management Strategy in Burkina Faso, Ethiopia, and Malawi.” The American Journal of Tropical Medicine and Hygiene 94(3): 568–570.
3 Ballard, M. and R. Schwarz (2018). “Employing practitioner expertise in optimizing community healthcare systems.” Healthc (Amst).
4 Crigler L, Hill K, Furth R, Bjerregaard D. Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving Community Health Worker Programs and Services. Revised Version. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co., LLC (URC). 2011.