Chapter 13: Community Participation in Large-Scale Community Health Worker Programs

By: Maryse Kok

This is the thirteenth chapter of the CHW Reference Guide 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.

Community health workers (CHWs) have an intermediary position between communities and the health sector, thereby improving access to health services for many people all over the world. This connecting position can also be challenging: on the one hand, CHWs are expected to conform to health sector guidance and performance targets, and on the other hand, they are embedded in and should respond to the communities’ needs and realities. Fostering the development of interpersonal, institutional, and community trust is therefore critical for effective CHW programs. Several studies have affirmed the importance of community participation in CHW programs since the Alma-Ata Declaration in 1978. For example, it can enhance utilization of services and community-based initiatives in health, and thus complement the role of CHWs in achieving universal health coverage.

Chapter 13 focuses on community participation in large-scale CHW programs. The authors, Karen LeBan, Henry Perry, Lauren Crigler and Chris Colvin discuss several key questions related to community participation and provide guidance for policy makers and program managers on what to take into account when developing and adjusting CHW programs.

Community participation: what does it look like?

Communities can participate in planning, supporting and monitoring health services and CHW programs, though the extent to which communities participate in all phases of the program cycle and levels of participation can vary from sharing information to full responsibility. CHWs support community participation through sensitization and education efforts, as well as simply encouraging the community to participate in activities. Selecting CHWs, providing support to and incentives for CHWs, establishing community-based referral systems or insurance schemes, mobilizing community members or vulnerable groups, and holding health facilities accountable for quality of care are ways for communities to participate in CHW programs.

How to stimulate community participation?

1. Designing CHW Programs to Enhance Trust

CHW programs should be designed to maximize trust among CHWs and their communities through CHW selection, role definition, training, supervision, and monitoring and evaluation. To ensure that selected CHWs are true representatives of the community and are capable of understanding the community, a wide variety of community members should be involved in the CHW selection process. Additionally, selection criteria should be carefully considered to avoid excluding particular groups. Furthermore, community trust can be enhanced by a formal introduction of CHWs and their tasks to the community with the assistance of local leaders. In some instances, communities create job descriptions and codes of conduct, which allows communities to tailor the CHW’s role to their needs. During CHW training, CHW-community relationships can be further enhanced by emphasizing soft skills such as empathy, listening, and expressing care. While uncommon, joint training of CHWs and selected community members has the potential to inspire community participation. Communities, often in the form of village health committees, can also have a role in supervision, monitoring and evaluation, and providing incentives for CHWs. These community-side support mechanisms need to be complementary to the existing structures in the health sector as successful joint efforts are proven to enhance CHW motivation and performance.

The above mentioned program elements vary in different contexts according to the desired health outcomes of the CHW program, the capacity of the community and the degree to which the cultural context is supportive. The authors provide an example of a CHW program in Honduras, in which teams of CHWs took ownership over their communities’ health. This involved CHW specialization, flexibility in operationalizing tasks, and providing rewards and incentives. This had a positive effect on community participation.

External factors, such as lack of resources, disinterest in community voices and ambiguity regarding forms of governance, are harder to influence and can have a negative influence on community participation. Policy makers and program managers should take these external factors into account and focus on internal program design factors that could enhance participation. The CHW Reference Guide presents an overview of barriers and enablers that should be taken into account.

2. Design of community participation policies and strategies

A policy or guidance document that outlines principles of community engagement assists in budgeting for community participation and enhancing accountability. Such a policy should be developed with the involvement of government, NGOs and civil society actors, as establishing buy-in and managing expectations at the national, district and local levels is essential. Non-governmental and faith-based organizations often have a longstanding role in designing, implementing and evaluating CHW and community participation programs which, together with other evidence bases, is advantageous for policy and strategy development. An abundance of vertical programs, however, should be avoided, as different CHW training, supervision, incentives and monitoring systems can undermine a national CHW or community participation strategy.

3. The role of community management structures

Community management structures, such as village health committees, provide support for CHWs by assisting in community mobilization and communication between the health sector and local administration. The performance of these committees depends, like that of CHWs, on the method of selecting volunteers, role definition, training, supervision, program performance evaluation and incentives. In addition, contextual factors, such as the extent of decentralization of the health system and power and trust relationships within institutions and among people in the society at large, influence strategies for community management structures.

In conclusion, the authors of this chapter state that community participation is of critical importance for well-performing CHW programs. As every community is different and dynamic, there is no one-size-fits-all approach in designing, implementing and evaluating community participation and elements of programs. In every context, partnerships, trust and respect between actors at all levels in the health system are essential to enhance positive and sustainable contributions to community health.

Maryse Kok, PhD, is a public health specialist and researcher at the Royal Tropical Institute (KIT) in Amsterdam. Her thesis was on conducting research on factors influencing performance of community health workers, with a focus on six countries in Asia and Africa: Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, and Mozambique. The research is part of the European Union-funded programme REACHOUT.