Improving the performance of community health workers: What can be learned from the literature?

By: Maryse Kok

This feature inaugurates the partnership of CHW Central and the Health Systems Global Thematic Working Group (TWG) on Strengthening and Supporting CHWs. In the future, the TWG’s research will be posted in a dedicated section on CHW Central.

Many countries are now attempting to roll out and scale up Community Health Worker (CHW) programmes. CHWs provide a wide range of health services. They are community-based workers who are trained, but have no formal professional or paraprofessional certificate. We conducted a systematic review of the literature to find out how intervention design can influence CHW performance to support governments and programme managers in increasing the effectiveness of CHW programmes.

How can we measure CHW performance?

CHW performance can be measured at two levels. At the level of the individual CHW, there are factors such as self-esteem, motivation, attitudes, competencies, guideline adherence, job satisfaction, and capacity to facilitate empowerment of communities. At the level of the end-user (the community), we can measure: utilization of services, health seeking behaviour, adoption of practices promoting health, and community empowerment.

Which factors influence CHW performance?

Contextual factors, including those related to community and political contexts

An example of a community-related factor is gender norms and values in the society. For example, in some countries, like Afghanistan, there is a preference for female CHWs working in reproductive health, as the society prefers women to interact with other women about their health issues. This same restriction also affects female CHWs as they attempt to involve men in reproductive health issues. This creates a barrier to performance, as female CHWs are not supposed to talk men outside their own families.

Health system factors, such as the way health care is financed and organized

An example of a health system factor is the availability and implementation of CHW-related policies. In Uganda, the lack of a regulatory framework for CHWs resulted in fragmentation of salaries among different types of CHWs and the lack of career opportunities resulted in the demotivation of CHWs and thereby lowered performance.

Intervention design factors

Intervention design factors influence CHW performance and are the easiest to intervene in comparison to contextual or health system factors. If program implementers know how certain features of an intervention effect performance, interventions can be shaped and adjusted to yield optimal CHW performance.

The most prominent factors related to higher CHW performance as found in the international literature are presented below.

Tasks and time spent on delivery
CHWs usually deliver preventive health services, but often they are more recognised by the community and have higher self-esteem and motivation if curative services are added to their tasks. A study in Zambia found that if CHWs spend more time with their clients, they perform better.

Human resource management
Selection of CHWs with specific characteristics, such as higher education level, experience with the health conditions to be dealt with, fewer household duties, and lower wealth lead to better competencies, good attitudes, and less drop-out of CHWs. For example, CHWs in Bangladesh who reported to be dependent on the income they earned through their work as a CHW were more active and less inclined to drop out as CHWs with more income.

A balanced workload, in line with expectations and incentives, enhances CHW performance. However, CHWs around the world often report about the negative effects of high workloads, for example increased loss to follow-up of patients. In addition, a lack of clarity regarding CHW roles often leads to unrealistic expectations from people in the community or health system, resulting in demotivation of CHWs.

A mix of financial and non-financial incentives, paid or delivered at a predictable time, generally enhances CHW motivation and thereby performance. Supervision is essential for CHW motivation. Performance appraisal generally leads to enhanced motivation and attitudes. Continuous training also results in better motivation and job satisfaction for CHWs.

Quality assurance
Use of standard operating procedures and programmatic guidelines is helpful, especially in settings using task shifting. CHWs’ role to facilitate community monitoring of health programmes in their areas can empower communities and at the same time satisfy CHWs. In Uganda, CHWs reported community feedback to be more influential in enhancing performance than feedback from their formal supervisors.

Community and health system links
In many CHW programmes, community support, selection, and monitoring are associated with increased CHW motivation and self-esteem. Recognition by other health staff leads to enhanced recognition from the community, leading to greater CHW motivation and self-esteem. Coordination and communication with other health staff were associated with better quality of care in Myanmar and higher coverage in hard to reach areas in Mozambique.

Resources and logistics
Sufficient resources and logistics, including transport and CHW kits, and the use of job-aids (simple tools used to support treatment decision-making) increase motivation and competencies of CHWs respectively.

How can we use this evidence?

The different intervention design factors as presented above often interact. To make it even more complex, something that leads to positive performance in one setting could have no effect or the opposite effect elsewhere because of differences in contextual or health system factors. Thus, there is no one formula for CHW performance. Having said that, there are some learning points that can be concluded out of the existing literature.

Responsibilities should fit with salary and other benefits: If CHWs are volunteers, their workload should correspond with a realistic number of working hours a week. Payment of CHWs should be considered when they have multiple tasks or tasks that require a lot of time. In some settings, CHWs are responsible for large numbers of people, spread out over vast distances, and this has a significant impact on the amount of time it takes to do their job.

Clarity about roles: Managers, professional health workers, CHWs themselves, and community members should all be clear about what is expected from CHWs. This sounds simple, but investments to gain this clarity can have significant effects on CHW performance. The job descriptions of CHWs tend to change and in some settings they are expected to take on the delivery of more curative services. It is important that expectations are managed as this takes place.

Strengthening CHWs’ linking position: CHWs are the link between health systems and communities. They seem to get the most satisfaction from their work with communities, but need support from the health system. Factors in the intervention design, like facilitation of support from traditional leaders or village committees and regular community meetings for performance feedback, can enhance community trust and respect towards CHWs. This increases CHW motivation and job satisfaction. Selection of CHWs by both community members and stakeholders in the health system can improve linkages of CHWs with both sides. In addition, proper supervision from the health system not only results in CHWs doing their job in the right way, but also increases the legitimacy of CHWs in the eyes of the community, boosting CHW motivation.

Maryse Kok is a public health specialist and researcher at the Royal Tropical Institute (KIT) in Amsterdam. She is working on a PhD, conducting research on factors influencing performance of community health workers, with a focus on six countries in Asia and Africa: Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, and Mozambique. The research is part of the European Union-funded programme REACHOUT.