Empowering CHWs, Engaging Communities

When implemented properly, volunteer community health worker (CHW) programs have helped achieve positive health outcomes by increasing the adoption of critical maternal and child health behaviors and practices. Yet, the success and sustainability of CHW programs is highly dependent upon understanding the social, cultural and institutional context in which they are implemented, and being creative and open to local design solutions. This discussion explores the critical operational decision making that goes into adapting some of the standard best practices for CHW program design and implementation.

The Manoff Group (TMG) has extensive experience in developing, implementing and evaluating CHW programs worldwide, and is currently engaged with CHW initiatives in Madagascar, Tanzania and Guatemala. Our approach to mobilizing community health volunteers is exemplified in the design and implementation of the extensively documented and successful AIN (Atención Integral a la Niñez) Program in Honduras, which has been adapted in more than a dozen countries. AIN specifically focuses on achieving healthy growth in young children through family and community actions focused on prevention and referral for curative care. AIN relies on small teams of community volunteers to serve as behavior change agents at the household and community levels. The success of the volunteers does not simply rely on building their technical skills, but on using their knowledge to determine the best plan for reaching all families and finding the right community group to implement activities that will address factors in the community environment detrimental to child growth. The AIN-type community volunteer programs have demonstrated success in improving practices, stimulating community action and, indeed, improving child growth outcomes. They have been taken to scale and have demonstrated sustainability because of volunteer engagement and community ownership.

A few of the best practices that resulted include:

1. Allow time in scale-up plans for community decision-making and engagement: In each community, the CHW program began with discussions between a health worker and community members about requirements and expectations. If a community agreed to participate, they selected a team of CHWs. Because the engagement/ empowerment process took time, AIN expanded at the rate of 2-3 communities per health center per year. It took about 5 years for all communities in the health center’s catchment area to be fully engaged in the program. In order to maintain community engagement, AIN community volunteers tracked and shared community-level data in quarterly community meetings, using bar charts to illustrate child growth over time. Community involvement is an essential aspect of a CHW program and it must not be overlooked in an effort to achieve program coverage. Community involvement also promotes program sustainability. How engagement is achieved, who leads the engagement and how it is structured varies by country and should be reflected in scale-up plans.

2. Prepare CHWs for their tasks in terms of the health system and NGO support: CHWs are often given one of the most difficult jobs: changing individual, household and community behavior. For decades, health professionals have not accomplished the task; but because offering “messages” seems easy, the job is shifted to CHWs. In reality, although CHWs may be in a good position to accomplish the task, they are not always appropriately prepared or supported. In AIN, CHWs were given short, participatory training, followed by a period of practice and follow-up, and monthly supportive supervision by trained counselors for their first six months on the job. During the initial training, a half-day was reserved at the end to allow CHWs to plan how they would execute their responsibilities and manage their cases. They also had tools to help them negotiate and track progress on behaviors at the household level. The program provided support on refining critical behaviors that would potentially make a difference given local epidemiology and culture.

3. Provide clarity on task expectations and flexibility on how CHWs accomplish them: It is generally agreed that volunteer CHWs should not be expected to work more than a few days a month or be overloaded with a huge number of preventative and curative duties. To reduce the work burden, AIN volunteers worked in teams of 2-3 per village. This increased retention and volunteer satisfaction. Importantly, AIN teams were empowered to determine how they would accomplish their tasks, building on each person’s skills and local context. This increased CHW longevity; and when they did leave, they often recruited and trained their own replacements. In some contexts, the teams of child growth promoters combined with other programs’ volunteers to form an even larger team of volunteer workers for the community.

4. Plan incentives and motivation that respond to CHWs’ need for recognition: Motivation and recognition are essential, but CHW programs continue to debate how best to do this. AIN found that non-monetary recognition, when planned, worked well and led to increased retention of CHWs. Each year, recognition activities were programmed and budgeted. Recognition was derived from the community and the health facility and included photo ID cards; caps and tee shirts; praise on local radio; a letter of thanks from the district health officer or minister of health; free use of public transportation; the right to move to the front of queues at the health center; free or reduced-price medicines in public health facilities; an annual party for CHWs and their families; seeing health indicators change; and, in some instances, the opportunity to work at the health facility for a small stipend. Being creative and responding to local input is critical to the success of non-monetary motivators.

Discussion Questions:

1. Should a community be required to commit to certain actions to support CHWs before the program agrees to train and support them? What motivates communities to support volunteer community health workers?
2. How do you build community capacity to participate in decision-making and move the program forward?
3. Is it desirable, and under what circumstances should programs form volunteer worker teams and allow CHWs to set their own agendas for achieving tasks?
4. What are the best ways to track key indicators and make progress (or lack of it) visible to community members?
5. What motivates CHWs to accomplish their tasks each month and continue to contribute over time?

Marcia Griffiths, President of The Manoff Group. Marcia Griffiths, MSc, is known for her fieldwork, technical expertise, and innovative programming in applied nutrition and social marketing. Her career includes over 35 years of program management and technical assistance work in Africa, Asia, and Latin America for numerous clients including host country governments, USAID and The World Bank.

Michael Favin, Vice President of The Manoff Group. Michael Favin, MA, MPH, has over 35 years of experience in international public health and has worked in more than 25 countries in Africa, Asia, and Latin America. Since joining The Manoff Group in 1987 to manage the Social Marketing for Vitamin A Project, he has served as a senior technical advisor or a consultant to numerous health and nutrition projects, including REACH, MotherCare, BASICS, Wellstart’s Expanded Promotion of Breastfeeding, OMNI, CHANGE, IMMUNIZATIONbasics, and MCHIP.

Paul Crystal, Communications and Knowledge Management Advisor at The Manoff Group.  Paul Crystal, MA, has been working for over 15 years to help international organizations and programs improve their approaches to communications and knowledge management. He was the USAID/BASICS project’s communications/strategic experience transfer manager, a position in which he applied innovative approaches to identifying and disseminating best practices to ensure easy access for counterparts in developing and developed countries alike.