By: Allison Annette Foster
This is the twelfth 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.
Summary
This chapter of the Reference Guide (Perry, Hodgins, Crigler, and LeBan) widens the lens of previous chapters to consider the community health worker (CHW) in the context of the health system. Chapter 12 advises national governments and stakeholders to plan in advance before scaling a CHW program to clearly define the health need the program will answer, the role that the CHW program will play in addressing that need, the resources required to sustain that role, and the support systems necessary to enable the success of the program. First, this chapter links the roles that CHWs play to the building blocks of the health system, highlighting the correlation between the functionality of the system and the effectiveness of the CHWs. Second, the chapter explores the relationship between the CHWs and other actors in the system, describing the support that is required from each of those groups, including community members, other primary care providers, and decision-makers. Finally, the chapter explores several models for integrating CHW programs into community health systems. The chapter argues that CHWs can play a significant role in improving the health system’s ability to deliver care and services, particularly in low-resourced areas, but that this can only be achieved through 1) a functioning health system; 2) the support of actors within the system; and 3) a defined and recognized role for CHWs as an integral part of the primary health care (PHC) service delivery structure.
An effective CHW program depends on the support of a functioning health system.
The chapter points out that gaps or weaknesses in the system will impede CHW performance and weaken the effectiveness of the CHW program. For example, if the CHW’s role is to distribute medications, such as misoprostol or antibiotics, then the CHW is in a position to contribute significantly to maternal and child health; however, she can only be successful if the health system’s supply chain consistently delivers the medications. In the role of health promoter, the CHW may be tasked to refer patients to the health facility and follow up with them afterwards. In this case, the CHW program may contribute to increases in facility utilization and improvements in antenatal care and post-natal services, but only if the information flow between facilities and CHWs is standardized, adequate, and reliable. Comprehensive health workforce policies are also important, providing clear job descriptions, adequate remuneration, and mechanisms for recognition so that the CHWs will be motivated and confident to carry out their roles.
A well-performing CHW program depends on support from other actors within the health system.
For the CHW program to successfully integrate into the national health system and effectively enhance the services that the system provides, the program must have the political support of decision-makers, the respect and cooperation of other frontline providers, and the trust and confidence of the community. Policy- and decision-makers play a pivotal role in the success of the CHW program by clearly defining the specific need the CHW program will fill and planning adequate resources for recruitment, training, remuneration, supervision, management, and supplies. Support from providers is equally important to enable respectful cooperation and task sharing between facility teams and CHWs. Community support is critical so that community members will engage with CHWs in preventative and promotional activities for the improved health of their families.
Various approaches have been used to integrate CHW programs into the national health system.
The chapter points out some particular strengths and challenges experienced in several of these approaches. The chapter describes, among other models: 1) the peripheral facility team model used in Peru, where a small outpost team is led by a nurse or midwife; 2) the Care Group Model, currently being scaled nationally in Burundi, where groups of volunteers are led by a promoter; 3) the CDI (Community-Directed Intervention) model, used in several countries, where CHWs help communities address specific diseases; and 4) the NGO management model with the example of BRAC in Bangladesh.
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| Community Based Volunteers support nurses at a rural health center. |
Reflections
Chapter 12 is particularly important as government leaders and policy-makers apply the guidance of the previous chapters to their national demographic and epidemiologic contexts. Moving from a district-level or regional program or from a vertical-oriented project to a national program requires the cooperation of many actors. This chapter identifies those actors and provides several examples of how those actors may be engaged in the process of integrating the CHW program into the existing health system. The chapter also enumerates the requirements for a successful CHW program, explained in depth in earlier chapters, guiding decision-makers as they plan strategies and budget resources. Challenges that are mentioned in Chapter 12 require thoughtful consideration:
- Functionality of the System: Health system building blocks necessary for the success of a CHW program are often weakest in the rural and low-resourced areas of the country, where the CHWs provide services. Therefore, scaling a CHW program needs to be part of a broader strategy to strengthen the entire community system, with benchmarks of improvement that may be correlated with the expansion of roles that the CHWs may play.
- Support of Actors: This chapter points out the disconnect between clinical professionals and CHWs. This gap should not be underestimated. The difference in education, culture, and even language creates barriers between the facility-based providers and the CHWs and community health volunteers (CHVs). Further, concerns that CHWs and CHVs undermine the professionalism of nurses and midwives and threaten low-cost labor alternatives continue to weigh on attempts to integrate CHWs into frontline teams. It will be important that nurses, midwives, and physicians participate in defining roles and job descriptions of CHWs, and that they participate in the policy discussions on how the CHW program will align with and support the important roles of the existing frontline team members.
- Evidence: To maintain the support of health system actors, to sustain the allocation of necessary resources, and to continually monitor the needs and strengths of the CHW program, evidence will be essential. Often, collection and management of data at the community level is weak, inconsistent, and even inaccurate. In planning a national CHW program, policy leaders will need to invest in data management systems and in building competencies at all levels to collect, manage, and apply information. These competencies will provide the necessary evidence to make improvements, demonstrate impact, and advocate for resources to continue to strengthen the CHW program and the community health system.
Conclusion
A scaled CHW program offers governments the potential to expand and strengthen their national PHC services and ending preventable maternal and child deaths. Enabling CHWs to effectively contribute to these goals requires a shift in previous perceptions of the CHW program as a temporary stop-gap. Policy-makers and influential actors will need to consider the CHW program as an integral and seminal component of a functional PHC system at the first level. They will need to plan the development and management of that program as part of a broader effort to strengthen the building blocks of the health system, particularly at the community level. Moreover, it will be critical that communities, providers, and influencers are fully engaged in that process.
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Allison Annette Foster, MA, is the Senior Advisor Human Resources for Health (HRH) at IntraHealth International and has more than 15 years of experience in health systems strengthening and health workforce performance improvement. She strives to develop the evidence base that links HRH investment to improved service delivery, stronger health systems, and better health outcomes. Prior to joining IntraHealth, Ms. Foster served as team lead for health workforce development and performance at University Research Corporation, Regional Advisor for the Americas with the World Health Organization/Pan American Health Organization, and various other HRH-related positions on facility and national levels for the Ministry of Health, the United States Department of State, and the Institute of International Education. |
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