By: Dr. Alfonso C. Rosales
This is the seventh 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.
Chapter 7 of the CHW Reference Guide describes CHW roles and tasks, and focuses on key points in planning, designing, or expanding new CHW roles. To be effective and efficient, community health worker (CHWs) programs need to be tailored to context-specific situations. Likewise, the roles and functions of CHWs need to be aligned with supporters and users of services, most importantly at the local level. Factors related to implementation feasibility, need, and safety should be incorporated within an operational framework. Moreover, the planning process requires that specific tasks be clearly defined in order to assure appropriateness to need, user and provider acceptance, and general support from the health system.
The World Health Organization recommends that planners take into consideration current research and evidence-based guidelines to ensure the effectiveness and safety of tasks performed by CHWs. Yet the lack of practical guidelines currently available for most local and international health program planners impedes progress. The authors, Glenton and Javadi, provide a thorough review of the most common roles CHWs have according to the most updated published and grey literature available. This review includes relevant and practical examples of national CHW programs currently being implemented in the developing world. The authors suggest that health planners address seven priority questions, laid out logically and sequentially, to build their design. Each priority question is presented with sub questions to prompt further considerations.
- How effective and safe will it be to use CHWs to perform a specific task?
- How can policymakers and program planners best assess the effectiveness, acceptability, and feasibility of CHW tasks for future interventions.
- Are CHW roles and tasks likely to be regarded as acceptable and appropriate by CHWs and their target population?
- Is there agreement among CHWs, beneficiaries, leaders, family members, and the wider community that roles are acceptable and their context and nature appropriate?
- How many tasks and activities should each CHW take on?
- Should CHWs be generalists or specialists? Are CHWs and community members involved in these decisions?
- When and where will each task be performed and what is the workload required?
- Are planners looking at the need for transportation, safety, quality, and incentives?
- What kind of skills and training will the CHW require when performing specific tasks?
- Is the task complex or tailored to recipients’ needs, circumstances, and local context? Is a complex diagnosis needed and are CHWs able to deal with complications?
- What type of health system support will the CHW require when performing the task?
- Are supervision, means of communication, access to supplies, and a referral chain in place?
- How much will it cost to use CHWs to perform the task?
- Are the costs of training, supervision, transport, wages and other incentives, equipment and supplies, and effective referral systems factored in?
Each question is succinctly answered using the latest literature and global available guidelines. Further practical and real-life examples from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe national CHW programs complement this information to bring an air of reality to the reader.
In conclusion, as a health planner practitioner, Chapter 7 was extremely useful in guiding my thought process, and helping me to include and understand the most critical components in designing CHW programs. Additionally, it provided me with the latest available evidence and resources to review in case a more extensive literature review is needed. An easy and enjoyable reading experience!
Dr. Alfonso C. Rosales MD, MPH-TM currently works as the senior MHCH technical advisor for World Vision US. He has more than 20 years of international experience in the child survival and maternal care/reproductive health areas, including field and headquarter assignments. For the last ten-plus years, he focused on Facility and Community Integrated Management of Childhood Illness (IMCI), providing technical assistance to country programs in Honduras, El Salvador, Nicaragua, Guatemala, Philippines, Cambodia, Philippines, Indonesia, Timor Leste, and Kenya. In the same topic, he has authored one manual on Community Based-Integrated Management for Childhood Illness (C-IMCI) for CHWs, several publications in peer reviewed journals, and participated in international conferences on the topic. Since 2012, he has been conducting operations research in South Sudan in the development of maternal and neonatal interventions to strengthen health system in fragile state settings. In this topic, he has led the development of tools for improving resolution capacity for identification and community case management of obstetric and neonatal emergencies, as well as referral systems. Additionally, during 2010, he co-authored a manual on community case management sponsored by John Hopkins University and USAID Washington. Dr. Rosales graduated from Tulane University, School of Public Health and Tropical Medicine, and the University of El Salvador, School of Medicine