Do we need a “Principles of Practice” for CHW programming?

There has been a resurgence of interest across the global health field in the use of CHWs to deliver essential health interventions at the community level, especially in countries with slow progress towards reaching the health MDGs. Many NGOs and agencies have prioritised the work of CHWs for improving health outcomes, but in most areas, and particularly those with weaker health governance, NGOs often operate CHW initiatives without strong and focused coordination of efforts. The possible consequence is that minimum standards, processes, quality and coverage, as well as long-term sustainable health systems strengthening approaches, fail to be consistently established. This is similar to HIV programming prior to the Three Ones Policy in 2004. The ‘Three Ones’ led donors, NGOs and developing country governments to agree to promote one action framework to coordinate the work of all partners; one national coordinating authority with a broad-based multi-sector mandate, and one country-level monitoring and evaluation system. Such coordination efforts, made with respect to community health programming and CHWs in particular, would benefit countries where CHWs are a priority health intervention.

Many iNGOs with a focus on global health worldwide are committed to improve child well-being and survival like World Vision; CHWs are a central component of community-based programs.  As part of this community committed to strong partnerships with government, World Vision is advocating for a simple set of “Principles of Practice” to provide guidance for programs across iNGOS to implement and advocate for more coordinated and country-led approaches.

Guiding Principles (Proposed)

Work with national and regional health authorities and partners in order to:

1. Advocate for the legitimization and recognition of the CHW workforce within the formal health system through appropriate country policies and initiatives that support registration, accreditation and minimum standards for the role and performance of different cadres.
2. Enable and support country leadership including national or regional coordination bodies empowered to provide oversight in CHW program implementation across partner organizations and health authorities.
3. Work with and through existing local health services and mechanisms to strengthen them, avoiding the creation of parallel CHW services, methods and supply chains or competitive working practices.
4. Establish standards and methods for performance-based incentives systems which are ethical, non-competitive and sustainable, and under a unified country policy.
5. Establish and agree on minimum standards for training of specific cadres of CHWs under an agreed unified system linked to performance-based accreditation.
6. Establish unified mechanisms for reporting and management of community health worker data that promote consistent quality monitoring, supervision and accountability to existing health structures and communities.
7. Invest in appropriate innovations judiciously through partnership approaches which will enable improvements to CHW work according to their capacity, and which are available within the public domain.

World Vision presented the principles for the first time in October 2012. We now seek to engage partners and donors, as well as partner governments, to call for the unification of programing approaches within a national framework, a more unified vision of CHW programing quality and standards, and to endorse these principles as a starting point for CHW programing coordination in-country.

Discussion Questions

1. Do we need a cross-agency agreement on CHW programming? How could the guiding principles best be used for leveraging partnership approaches and coordination?
2. What steps can be taken to ensure that country coordination and regional coordination among NGOs will be implemented effectively and will lead to positive results?
3. Given that competitive and diverse incentives among different NGOs impact the quality and sustainability of CHW programs and lead potentially to competitive working practices, is it feasible and desirable to develop or push for a ‘one-country, one-policy approach’  to incentives, especially financial ones? 

We welcome any further discussion and comments on the guiding principles. For more information, or to review a copy of the World Vision Principles of Practice for CHW Programming, contact Polly at: polly.walker@worldvision.org.uk. 

Polly Walker, D.Phil is currently the CHW Programming Advisor for World Vision International. Her career includes 10 years of working in west and southern Africa and Asia as a researcher and program development advisor in the areas of HIV and maternal and child health. Her interests are CHW and TBA training and health systems research

Mesfin Teklu, MD, MA is the Director of Maternal and Child Health, HIV and Infectious Diseases for World Vision International where he provides strategic leadership in health policies, strategies and programs. He has more than 18 years’ experience in public health, nutrition and humanitarian assistance working in Africa and Asia.

Fe D. Garcia MD MPH, Sr. Adviser, Child and Adolescent Health & Development for World Vision has over 35 years of combined global experience in community and child health including training of Mother Health Workers and Village Health Committees in the 70s in the Philippines as well as other public health practitioners.