Chapter 16: Case Studies of Large-Scale Community Health Worker Programs

By: Polly Walker, PhD

This summarizes Appendix A 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. 

Appendix A of the CHW Reference Guide provides an in-depth view of 13 large-scale CHW programs drawn from diverse settings (Afghanistan, Bangladesh Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia and Zimbabwe). The programs are mostly government/public-sector, but notably include one large-scale NGO program, BRAC (Bangladesh Rural Advancement Committee), which currently supports over 100,000 CHWs globally. Many of these programs have been mentioned throughout the guide already. However, in the case studies they are viewed within their historical and policy context and their integration within the health system, with an exploration of challenges and successes provided by key informants. Each study is structured in the same way– addressing most of the critical implementation points, how the CHWs are selected, trained, supervised and deployed in each system, as well as the role they take in the formal health sector and in community engagement. The collection presents insight into how CHW programs have evolved in diverse regions including South America, Africa, Asia and the Middle East since Alma Ata to the end of the MDG era.

In reading these studies, several key concepts emerge. Firstly, there is an extraordinary diversity of the ways in which CHWs are being engaged across the globe and in different development settings. Many programs have been evolving for more than 20 years and aiming to meet the changing health needs of their populations. Even now, many policy-makers in low-middle income countries consider CHWs as a ‘band-aid’ for failing health systems, and simply a stop-gap until the real aim of building skilled health-workforces can be achieved. In the country programs described here, you will see, this idea really isn’t evidenced. The roles and tasks that CHWs play in health system strengthening have in fact expanded, rather than being diminished through economic development. They have become increasingly recognised as a major component of effective national health strategies, and their importance has in no way been devalued as the formal health workforce expands.

Most of the studies describe programs that started from small beginnings in the late 1980s or early 1990s, with CHWs focussed on health promotion and treatment of childhood diseases, aimed at quickly reducing preventable child deaths. As programs have grown in size they’ve also expanded in scope and complexity of services provided to include services with higher level competencies such as HIV and TB care, family planning, immunizations, injectable contraception, and newborn care. Typically, only the long-running successful programs, have been able to include components such as distribution of misoprostol and chlorhexidine distribution, and management of newborn infections using injectable antibiotics (e.g. Nepal and BRAC). Several countries, such as Ethiopia and Rwanda, appear to have staggered the task-shifting of family planning provision to the CHW level once the program was well established, and in these cases, has led to a dramatic increase in access and coverage. In Brazil, the role of the CHW has evolved towards more of a rehabilitative and supportive role in the community with a focus on management and prevention of non-communicable diseases, reflecting the epidemiological shift. This emerging trend is also seen in India and Bangladesh. CHWs are able to provide community-level support and to target specific at-risk populations that health services may not otherwise reach, and therefore may well continue to be the cost-effective solution regardless of economic development of a country.

There is huge diversity in the history and financing of CHW programs. Most have been launched from pooled resources and multi-stakeholder initiatives driven by bilateral donors, World Bank, UNICEF and Global Fund and other NGOs, with government gradually taking over elements with domestic finance. However, in the most successful programs it’s been about how well the government has used donor finance towards building a comprehensive system than the contributions of donors alone. Most countries, with the exception of Brazil and Iran, are sustained by a combination of donor, NGO and domestic finance, and the national funds are often used to establish fixed salaries whilst partners support the program ‘software’, for example in Nepal, Zambia, India, and Pakistan. Many country programs that are less successful and have failed to reach scale are still fragmented by conflicting donor and NGO interests which have not been reconciled. Domestic finance through centralised funds or national health insurance schemes clearly emerge as an essential ingredient for successful scale.

Another key concept is that CHW program success factors have more in common than not, and remarkably, implementation challenges are practically universal. Common success factors include the consistent embedding of CHW programs in health systems, formal links with health services, and community engagement through health committees in which the role of the CHW is supported. There appears to have been a gradual shift towards incentive payments to salaries for a ‘low-level formalised cadre’, although with continuing roles for volunteers. Several countries have shifted towards multi-cadre systems involving a combination of formal low-level workers and community volunteers (Ethiopia HEWs and Health Development Army; Bangladesh national CHW program). There are cases in which the CHW programs have been very successful and yet have remained an unsalaried voluntary workforce. They’ve achieved this through building team-based approaches to share the workload (Rwanda, Afghanistan, Indonesia), providing collective support for income generation (Rwanda), and where community cohesion and embedding is very strong (Indonesia). Another common success factor is the link to gender empowerment: most CHWs are in fact women, typically with little more than a primary level education, but the CHW work enables both economic empowerment and enhances the respect for women’s contribution in the community. In the context of the BRAC program the switch from male to female CHW enhanced its sustainability, although in other settings a predominantly female workforce has led to increasing concern for their security, such as Afghanistan and Pakistan. 

The common, almost universal challenges appear to include consistent remuneration whether incentives or a salary, ensuring CHWs reach isolated/marginalized communities and populations, sustaining commodities and supply chain, and providing regular supportive supervision. Some of these can be addressed through good integration with health systems, enabling the program to be sustained and effective. However, where health systems have themselves declined, been overly de-centralised or lack support, it is the CHW systems at the bottom of the food-chain that suffer the most. In the context of Zimbabwe where a successful VHW program had been scaled up, in the 1990s the economic downturn and political problems saw the VHW program diminish to less than 20% coverage which likely made a big contribution to the increases in child mortality. Pakistan, having established its well-known Lady Health Worker program over decades, having decentralised health administration completely to provincial level, has become increasingly varied in the functionality and mandate of the LHW workforce.

Conclusions: What works in large-scale programs? Here are the key take-home lessons from this extraordinary collection of case studies:

• Recognise the need for this workforce independently of doctors and nurses. CHWs, with the right support and political leadership, can move epidemiological mountains at a fraction of the cost of medical training. Don’t think of them as a short-term fix –  their roles can evolve to meet the changing needs of the demographic.
• Start small and build from the base, ensure government leadership especially in directing the utilisation of donor funds towards a strong core program, enshrined in a solid policy and five-year strategy.
• Envisage multiple cadres in a team approach, including potentially both voluntary and non-voluntary players.
• Create a cadre of supervisors; don’t deploy a CHW workforce expecting overburdened health staff to manage that role.
• Don’t decentralise the health system until you have a solid functional CHW program up and running; this will lead to further fragmentation of the community workforce, reducing cost effectiveness and wasting money on parallel planning and training exercises.
• Channel national insurance into providing basic commodities and supply chain strengthening, start getting creative and direct what you do have towards intelligent income generation and endowment funds.

Bio:  Polly Walker has provided technical leadership to World Vision’s community health worker (CHW) program portfolio over 5 years. During this time she has overseen their expansion of CHW support growing from 70,000 in 2011, to over 220,000 CHWs in 48 countries. She is the co-author of Timed and Targeted Counselling: a comprehensive course for community health workers, now operating in 38 countries. Over the last 12 years of her career she has focused on CHWs, authoring over 20 CHW training modules, designed mHealth applications used in 7 countries, written various publications on ICCM, quality assurance and supportive supervision, as well as the Core Group’s CHW Principles of Practice in 2013. Polly is known for her work as an advocate for government-led harmonization and scale-up, as well as for her work in developing innovative family inclusive psychosocial approaches to community health care.