Community Health Worker Assessment and Improvement Matrix Operations Research

By: Rebecca Furth, Ph.D.

As we near the 2015 target for the Millennium Development Goals, vast challenges remain to providing accessible health care for underserved populations. The global public health community recognizes that we can’t reach key health goals without community health workers (CHW). Yet, we have few tools for assessing – let alone improving – community health worker program functionality.

How do we improve CHW programs while recognizing and supporting their diversity? How do we ensure that CHWs adhere to the minimum service delivery standards that every client deserves? And what do strong community-health facility linkages look like and how can we promote them?

In response to these (and many other) questions, Initiatives Inc. developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM), funded by USAID through the HCI Project. CHW AIM provides standards for various program aspects (recruitment, supervision, training, linkages to the health system, etc.) and guides program managers, staff, partners and CHWs through self-assessment and action planning. Initiatives field-tested the CHW AIM tool in Nepal and Benin; other partners, including WHO, have tested the tool in various locations. However each of these uses was a one-time application, so the question remained: can the CHW AIM tool help improve CHW programs?

To put the tool to the test, in 2010 we initiated a “CHW AIM Operations Research” (OR) with five CHW programs in Zambia. The five partners are implementing the CHW AIM process twice over 15 months. In addition, we have included one control site. The OR will document areas of improvement and the specific interventions that led to them.

We also want to know more about the relationship among program functionality, CHW engagement (commitment to and excitement about work) and performance (completion of tasks compared with national standards). So we are also measuring CHW engagement (through a survey and interviews) and performance (using recordings of service delivery to measure achievement of service delivery tasks for HIV treatment adherence support and positive living counseling). Finally, we are looking at the costs of implementing CHW AIM, as well as any costs for incentives, supervision, or training that might result from implementing the action plans.

Where are we now? We completed the baseline for the CHW AIM OR in November 2010. The five partners liked the process. As expected, some of the programs were stronger than others, but there were also some common strengths and challenges:

• Common strengths: Recruiting CHWs and defining their roles.
• Common challenges: Country ownership, individual performance appraisal, program performance evaluation, referral systems, opportunities for advancement, community involvement, and supervision.

Our baseline data suggest some correlation between program functionality as determined by CHW AIM, and CHW engagement and performance, though only subsequent data collection will show if improving program functionality results in improved engagement and performance.

We’re constantly learning as we work through this research program. As you reflect on my post, please share your insights on the following:

1. What measures does your program use to assess functionality, engagement, and performance? Have you seen correlations among them?
2. How do we strengthen the integration of national CHW programs and the myriad NGO-managed CHW programs to contribute to national outcomes?
3. What should performance appraisal systems for CHWs look like? And what is practical given the budgetary and human resources constraints of most CHW programs?
4. What are the most effective methods for galvanizing effective community leadership for CHW support?

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Rebecca Furth is a Senior Technical Advisor at Initiatives Inc. She provides technical support in human resources management, research, quality and performance improvement, organizational capacity building, and training for national health systems, NGOs and targeted HIV/AIDS and reproductive health programs. Originally from the U.S., Rebecca currently lives in India. She trained as a cultural anthropologist and has worked in Africa, Asia, the Middle East and the Caribbean.