By: Michaela Cisney & Polly Walker
The rapid scale-up of community health workers (CHWs) has been recognized as a global priority in achieving universal health care in the hardest to reach communities and health workforce crisis settings. A single CHW, well trained and supported, can provide essential basic health services to communities that otherwise would have limited access to healthcare. One CHW serves an average of 650 people. In 2013 at the Third Global Forum for Human Resources for Health in Recife, Brazil, World Vision (WV) made a commitment to support 100,000 CHWs by 2015, enabling us to reach an estimated 5.6 million children a year, globally, with basic health services. This modest commitment was based on 2011 data, which estimated 70,000 community-based health workers supported globally by World Vision at that time.
World Vision contributed to the development of a framework to harmonize the myriad of different CHW programme approaches currently in use by diverse partners and NGOs, based on our CHW Principles of Practice. The fragmented implementation of CHW programmes by multiple NGOs and donors has led to difficulties with country ownership, nationalization, and counter-productive approaches: it has undermined the goal of collective action that the Millennium Development Goals (MDGs) were intended to inspire. As a result, many countries have failed to realise and unlock the potential of the CHW workforce in reducing maternal and child death. Since making this commitment to harmonize in 2011, WV has undertaken a monumental effort to scale up CHW programmes, especially in settings where health workforces are critically low and inequities in rural areas have caused failure to achieve the MDGs, and partnering with government, donors, and NGOs to support collection action.
WV is one of the largest NGOs working in global health and development, with field operations encompassing over 100 countries, involving over 45,000 staff. Historically, WV has been driven from the grassroots, meaning that field operations are decentralized to country level, and sometimes even to project level. As such, data systems, quality standards, and operations have been incredibly diverse within and between countries until recent years. Part of our own CHW programming journey to scale has included moving from multiple disconnected projects to adopting national technical approaches, defined by a set of programming quality standards, standardized monitoring indicators, and data systems (Horizons). All offices and projects are gradually adopting this system. Standardizing CHW counts has proved an enormous challenge, especially when considering the diversity of the cadre, definitions and scope of policy development across all such countries. As such, creating a global estimate to report on our progress against the Recife commitment has been a priority, but one that comes with considerable challenges. The Frontline Health Workers Coalition released a report proposing a methodology for defining CHWs and capturing diverse cadres under a single definition, launched at Health Systems Global in 2014. Since that time, we have been working on standardized reporting with national offices and exploring the feasibility of the Frontline Health Workers Coalition approach.
To better understand World Vision’s progress on standardizing CHW data collection, to explore CHW data counts, cadres and activities, and to get an estimate of our current global CHW portfolio size, we undertook a global census to capture these counts in 66 national offices with health programming, with some impressive results. World Vision’s own journey from fragmentation to harmonization is one that gives insight for the CHW community at large, and has implications for the counting of CHWs both globally and nationally.
The global census was conducted via survey and interviews in late 2015, involving 66 WV national offices. The survey was designed on the definition of CHWs offered by the International Labour Organisation (ILO) in 2008 and recommended for use as a guiding framework in the Frontline Health Workers Coalition 2014 report. Survey data validation was done through review of submitted reports, documents, and phone interviews. The validation process involved considerable clarification around ILO’s CHW definition, finding that country offices tended to exclude data if cadres weren’t officially named “CHW” in country policy, or if CHWs weren’t formally recognized by the Ministry of Health (MOH). Active community volunteers such as Care Group volunteers, Mothers Support Groups, HIV expert clients and many others, were included in counts after further clarification. This finding suggests it would be more useful to apply a two-tiered definition of CHWs, distinguishing those formally and informally engaged in health activities with the MOH.
The report findings show that World Vision supports approximately 220,370 CHWs globally, more than twice the projected target for 2015, and that CHW programming is a core approach for health and nutrition operations in 48 of our national offices. In terms of programming for scale, significant progress has been made; 34 of 48 national offices are currently reporting that we have active CHW programmes reaching 50% or higher of our project sites.
|Figure 1 Community health worker programming reach within World Vision operational areas (n=48)|
World Vision released its “CHW Principles of Practice” in 2013, and adopted as policy for health programmes the commitment to align and support harmonized national CHW programmes with support of multiple stakeholders. In terms of harmonization, 80% of the ministries of health in these countries currently have an existing national CHW policy in place. Where a national CHW policy exists, World Vision CHW programmes are fully aligned with the national CHW policies of the ministries of health in 65% of cases; i.e., we are implementing or strengthening a national CHW programme. The majority of deviations from alignment were attributed to research and innovations, proof of concept pilots, or grant-funded programmes. The results show that promoting harmonization with partners and governments to bring CHW programs to scale is yielding significant progress on the ground and should be continued. Our efforts to scale up standardized monitoring systems are also well underway, but the methods and definition of the CHW cadres need to be refined so we can accurately report country level data relevant to the MOH and civil society cadres.
The findings illustrate the vast scope in WV’s existing CHW portfolio, but also the considerable potential our national offices hold in contributing to scaling up CHWs where they are most needed. It doesn’t mean our work is done, however! Whilst we may have surpassed our previous targets, we are still experiencing severe health workforce gaps; many national offices in health workforce crisis countries are still operating at less than 50% reach. Continuing to scale-up harmonized, cost-effective CHW programmes will remain our priority for some time, not only addressing data gaps, but ensuring that sustainable financial models are established, especially in those areas where project start-up funds have been boosted by grants and major donors.
 Singh Pa. One million community health workers: technical task force report. New York: Earth Institute, Columbia University; 2011.
 Walker et al., 2013 “CHW Principles of Practice: Guiding principles for non-governmental organizations and their partners for coordinated national scale-up of community health workers” http://www.coregroup.org/storage/Program_Learning/Community_Health_Workers/CHW_Principles_of_Practice_Final.pdf
Frontline health Worker’s Coalition, 2014 “A commitment to community health workers: Improving Data for Decision-Making.” http://frontlinehealthworkers.org/wp-content/uploads/2014/09/CHW-Report.pdf
Michaela Cisney is consulting project officer for World Vision’s CHW global census, report, and communications.
Polly Walker is World Vision International’s CHW Programming Advisor
For more information about World vision’s Global CHW Portfolio visit http://www.wvi.org/health/map/world-vision-chw-global-programme, email: firstname.lastname@example.org or follow Polly Walker on Twitter: @DjennaBu