By: Emma Sacks
It’s all too common a problem in global health for a successful community pilot program with intensive support and investment to face a number of challenges in later phases when efforts are made to expand, replicate or scale-up the program. While community health worker (CHW) programs may be relatively inexpensive for a small geographic area or over a short timeframe, there is often a lack of planning and resource commitment for the institutionalization and support for CHW programs at scale in the long term.
The CHW Reference Guide[1] has a helpful chapter on “Scaling Up and Maintaining Large-Scale CHW Programs,” which highlights the importance of careful planning, ongoing monitoring with allowance for iteration and effective political engagement with multiple actors and stakeholders from the outset. The Guide makes the assumption that CHWs will be guiding the scale-up of a national CHW program, but does not go into detail about the various possibilities for managing multi-cadre systems, which may include coordination and regulation of both Ministry of Health-supported and NGO or partner-supported CHW cadres.
The Guide asks planners to consider what they expect the CHW program to look like, what type of planning is needed to reach scale, what potential pitfalls might be, and what contextual factors or external conditions are important for success. Key issues listed involve an early understanding of the complexity of the activity, an assessment of the local needs and capacity, knowledge of specific program requirements, a plan for ongoing monitoring and evaluation, and strategies for ensuring equitable coverage. Planners should also make realistic estimations of both start-up and recurring costs to maintain the program. If CHW programs are designed to be embedded within the national health system, planners and policymakers should map out the potential implications of the program on the existing health system, including the effects on managers and clinical staff both within and beyond the health sector.
Work-plans for CHW programs have to consider many stakeholders and a number of different procurement and management issues. These include supplies of medications and equipment, human resources, supervision and accountability structures, legal and regulatory issues, and quality assurance processes. Programmers also must consider the most strategic way forward for scale up. It might be through horizontal expansion, which aims to increase the number of beneficiaries receiving the same services, which can occur through additive replication or multiplicative growth. Programmers can also consider vertical expansion, which aims to institutionalize the program through high-level policies that need to be in place prior to project roll-out, which may take longer to set up but are more likely to be sustained. CHW programs can also grow through diversification, where tasks or services are added to current CHW responsibilities, although this carries a risk of reducing the caseload any given CHW can then cover. Efforts to be realistic and rational about the types of expansion desired during the planning phase can have larger positive impacts on programs in the long-term.
The Guide also warns against common challenges to scale up such as lack of coordination among partners, conflicts over the use of current vs. new cadres of CHWs, the promotion of un-scalable pilots, underestimation of budgets or long-term costs, failure to understand the complexity of the interventions, too rapid a pace of geographic spread, poor quality training and supervision of CHWs, lack of codified CHW competencies, and poor adherence to and regulation of basic clinical standards. Envisioning the scale-up process merely as a training cascade generally will not produce desired results, because the needed support systems for different levels of CHWs will not be in place. Ultimately, national CHW programs are most often doomed by the fact that they were scaled-up without a plan or the allocated resources for sustainability over at least a decade.
In order to sustain impact at scale and program momentum, the CHW program needs to be a priority even after the initial scale up phase. One recommendation for keeping the CHW a priority within the Ministry of Health is to set up a Technical Working Group with regular meetings and a diverse membership that is committed both to the process and the outcomes. In order to sustain impact, services must stay relevant and accessible and the quality of services must be continually high. Recent research shows that to stay motivated, CHWs desire fair and timely pay, respect from peers and supervisors, and opportunities for professional advancement.[2]
The Guide presents two conceptual frameworks widely promoted for scale up: the ExpandNet/WHO Framework[3] and the Management Systems International (MSI) framework[4]. ExpandNet comprises five components and seven attributes thought to be necessary. This model asks the user to consider if there are ways to simplify the innovation or service while retaining the essential components. This streamlines the scale up process while ensuring that the desired outcomes can be reached. The MSI model has three steps and focuses on adapting projects in to the local system to reduce reliance on unpredictable donor funds.
Many organizations focus on the parts of a health intervention that can be controlled, but the environment and local context can greatly influence the success of a scale up effort, as well as the choice and pace of strategies. Understanding the political and donor environment can help policymakers choose between phased vs. rapid approaches and focused vs. integrated packages of interventions. Taking advantage of politically opportune moments must be balanced against the long-term goals and realities of the project. The Guide defines three important contextual factors to consider: (1) local epidemiology, demographics and burden of disease; (2) the current mix, density and coverage of primary health care services and public-private mix of providers; and (3) the current strengths and weaknesses of the local health system, including governance, finance and sustainability.
In order to effectively scale-up CHW programs, a number of elements must be in place: strong leadership, fit to the local context, long-term financial investment and continual monitoring and improvement. Most importantly, planning from the beginning is needed, which takes into account the needs and expectations of beneficiaries, and the projected impact on health outcomes. As CHWs expand from largely rural programs, to national ones, lessons can be learned from efforts in many countries. The Guide provides examples of scaled-up of CHW programs from India, Brazil, China and Bangladesh. Newer examples are also now emerging from Ethiopia and Malawi, as governments work on equipping, expanding and standardizing cadres of CHWs and embedding them into the national health system. Monitoring and evaluation systems should be built into programs, and opportunities for iteration and adjustment allowed to continually improve, strengthen and grow CHW programs.
[1] www.chwcentral.org/developing-and-strengthening-community-health-worker-programs-scale-reference-guide-and-case-studies
[2] human-resources-health.biomedcentral.com/articles/10.1186/s12960-015-0082-7
[3] www.k4health.org/toolkits/fostering-change/expandnet-who-tools-fostering-change
[4] www.msiworldwide.com/approach/tools/scaling-up-framework-toolkit/
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Emma Sacks is the Community Health and Implementation Research Specialist at USAID’s Maternal and Child Survival Program (MCSP) and Associate Faculty in the Department of International Health at Johns Hopkins School of Public Health. Her research focuses on the intersection of newborn health and HIV and the role that families and community health workers play in obstetric and infant care in resource-limited settings. Dr. Sacks is interested in strategies to promote mutual respect between patients, providers and community members, and has a strong interest in processes for scale-up and sustainability of successful interventions. |
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