By: Daniel Palazuelos
This is the eighth 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.
This chapter focuses on what might seem like a simple step in CHW program construction: the recruitment and selection of CHWs. This chapter shows us, however, that getting the right people to do the right job well requires thoughtful planning and knowledge of common pitfalls. If implemented thoughtfully, the authors explain how the process by which CHWs are employed can be the crux that decides whether: 1) that program will reach its highest aspirations, 2) the community will be given substantive opportunities to engage in the process, and 3) the program will later be hobbled by unacceptable, and expensive, levels of attrition.
The (so-called) standard procedure of recruiting, selecting and hiring (and where it can go wrong)
Ideally, the CHW recruitment process will cover the following steps: “establishing criteria, communicating CHW opportunities to identify candidates, interviewing and selecting CHWs from candidates, and hiring selected CHWs.” Commonly, this can look like the following: the CHW program advertises a position in local media, communities nominate candidates via civil society organizations or public gatherings, and finally the program makes hiring decisions based on internal criteria like literacy and attitude. Variations exist, but increasingly in most programs, the community is only consulted whereas the health system holds the final power to choose “who makes the cut.” As one community organization representative once said “when it comes to ‘community participation in health,’ we participate, but they decide…” What this statement, said with discontent, tells us is that deciding is power, and if that power is not shared in some substantive way, communities can feel disengaged.
The holy grail of selection and community engagement – balancing education and participation
The Alma Ata Declaration was not only an announcement but also a challenge: “Primary health care (PHC) requires and promotes maximum community… self-reliance and participation in the planning, organization, operation and control of PHC.” Control is the operative word here, but it goes on: “and to this end [PHC] develops through appropriate education the ability of communities to participate.” What is being described is the balance between empowerment in the form of guidance and pragmatic solidarity (which means being cognizant of how solidarity should also be shown in material ways), and partnership in the form of shared decision-making and mutual respect.
CHW selection is a key point where this balance between community control and learning to participate can set out on the right, or wrong, foot. Power sharing is manifested by the attitude and actions of program architects and staff when interacting with target communities and local leaders. Practically, this means assuring that the program is well aligned with community priorities and that clear mechanisms exist to not only make decisions collectively through democratic processes, but also share resources fairly. This is not straightforward, but this chapter gives many examples of where this has worked. What follows are key lessons learned, boiled down for quick consideration.
What to do
Program performance can only be as good as program design. Program architects, namely those stakeholders who can influence how funds will be used, should begin by considering the roles, responsibilities, and tasks that CHWs will undertake. Concretely, the tasks a CHW is asked to do is what they and their beneficiaries will see every day. A common mistake is to decide on a mission, i.e. to reduce maternal mortality, and then immediately begin recruitment without a clear map of how CHWs will contribute. In the case of maternal mortality, for example: will CHWs educate mothers, accompany them to birthing centers by walking many hours, and/or provide misoprostol and gentamycin in emergencies during home births? These tasks require different skills, different levels of support, and may be best performed by different candidates: perhaps older women will be most credible to educate mothers to change behavior, while only the healthiest could walk for hours each day to accompany patients to health centers.
Literacy is often important, but not everyone who knows how to read also knows how to counsel and persuade. For example, our CHW program in PIH-Mexico involves behavior change in the most marginalized communities with chronic diseases; for this reason, we prioritize a local reputation for compassion over reading and writing skills (although all applicants must have some basic literacy). Imperfect literacy may lead to poor spelling in reports, but the real goal is not grammar – it is to reach and support people as they begin to live their life with a new diagnosis. PIH-Mexico involves behavior change in the most marginalized communities with chronic diseases; for this reason, we prioritize a local reputation for compassion over reading and writing skills (although all applicants must have some basic literacy). Imperfect literacy may lead to poor spelling in reports, but the real goal is not grammar – it is to reach and support people as they begin to live their life with a new diagnosis.
With a job description of high-value tasks in mind, program architects can then build out an effective programmatic milieu: what tools, what levels of supportive supervision, what financial incentives, will be most useful? Recruiters can present this full package of support to potential candidates to communicate what they are signing up for. The more concrete the terms of engagement, the more assured one can be that a CHW is signing up with clear expectations of what lies ahead.
Now with a job description and support system mapped out, program architects can confidently define the target community, and consider whom in that community is available to do the job best. Program architects need to be close to, and in continuous dialogue with, the communities being served. How to maintain this communication is not straightforward, but it usually entails being present often, walking on-site and having regular conversations with local leaders and with intended program beneficiaries. To say it simply, the best CHW program decision makers will usually make those decisions with dust on their shoes. This can be logistically challenging for large programs, or for those that have to recruit from outside of target communities because of a shortage of available candidates, but this type of close feedback should be seen as a non-negotiable and sought out.
What NOT to do: common pitfalls and challenges
There are many ways in which CHW selection can run awry. Here are top considerations both from this chapter and my own experiences:
- Recognize and mitigate nepotism early: if the nomination or selection process is left to powerful community members, they may favor their friends and family over talent. One way to avoid this is to offer multiple, simple methods for candidate nomination, and then follow a transparent selection process that allows best candidates to stand out to both program directors and community leaders, such as observing candidates performance in a mock patient encounter. Here is a key example where participation and education to participate are critical to get right; setting a standard that nepotism is not acceptable is okay, as long as the rationale behind this is well explained and such limitations are not placed at every decision point. The ultimate goal is to be as adaptable as possible.
- Consider the candidate as a full package: many programs demand a lot of CHWs and seek to hire only those with the highest literacy, considering this a proxy for ability. A focus on any single, measurable trait can lead to tradeoffs. In the case of high literacy, for example, men and young people may have greater access to schooling, while older experienced female caregivers with great social capital and compassion may be largely excluded from selection. Higher literacy candidates will also often have other options and may be harder to retain long-term.
- Simple definitions of “community” may lead to complex consequences: program architects’ decisions will only be as good as their understanding of the community. If this understanding is superficial, it may lead to a program that crumbles under the weight of rocky performance. A classic example is considering “a community” to be people living in a certain geographic area. Yet, as we know from our own neighborhoods or workplaces, people in a single area may divide among themselves into many sub-communities. Sometimes these groups hold deep-seated resentments and mistrust for one another. Hiring a CHW from one sub-group to represent another will often simply not work. Key moments of community engagement, such as when CHWs are recruited, can bridge or inadvertently reinforce these schisms, especially when that engagement confers material benefits like employment and social capital. The best way to avoid this, again, is to walk and talk with the beneficiaries, asking the right questions, to truly understand who they are, whom they trust, and what openings there are to make bridges or avoid pitfalls.
- Attrition should be considered early and planned for well: this chapter has a lot of great advice on how CHW retention can be fostered. Every program will experience some level of attrition, however, so it is worthwhile to make a plan on how to quickly and efficiently refill vacancies. One idea we are piloting in Mexico is to over-recruit initially, select all eligible candidates, and keep some on a waiting list for later employment. Those on the waiting list should come to all trainings to stay eligible, and once a spot opens they can immediately fulfill the role. This specific strategy may not work in all programs, but all programs should make their own strategy so that positions remain filled and communities do not experience a lapse in services.
Concluding with a word of caution
In closing, this chapter teaches us that selection is not merely a simple bureaucratic step, but is rather a key process that will effect a program’s performance and long-term CHW retention. Combatting attrition requires a close look at the many facets of worker motivation, but it starts with thoughtful recruitment. A group of CHW experts at PIH and I developed a CHW framework called 5-SPICE. This is an acronym for 5 essential elements that are necessary for any program to consider, not only as a checklist but also a heuristic exercise to reflect on how those elements are interacting. The “C” in this model represents what we called “Choice” – which is not only how program leaders choose the best candidates, but also why those candidates choose to fulfill the CHW role. It’s about power sharing; at the point of hiring, it may seem that they who hire have the ultimate power, but since CHWs can walk away at any time from their jobs, taking with them all the investments of training and mentored experience, we see that it is they that ultimately have the greatest power. With this in mind, power sharing can be considered an investment, and the return may be measured in long and fruitful partnerships. So much will depend on how the first steps are taken, and these steps are often taken during the recruitment process; it pays to start off right.
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Dr. Daniel Palazuelos has over a decade of experience working with CHWs. This includes: living alongside CHWs in rural Mexico for months on end during his medical training, serving as a quality improvement manager with CHW programs around the world at the NGO Partners In Health (PIH), leading the launch of new CHW programs with PIH in Chiapas, Mexico (locally known as Compañeros en Salud), and working with member organizations of an academic advisory initiative called the Community Health Systems Initiative (CHSI) in the Program in Global Primary Care and Social Change at Harvard Medical School. Most recently, he worked with the UN Special Envoy on a report highlighting the benefits from investments in CHW programs. |
Photo credit: Lucy Perry/Hamlin Fistula Relief and Aid Fund Australia
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