S-AIM: Health Systems Assessment for CHW Program Improvement – Experiences from Uganda and Kenya

By: Michele Gaudrault, World Vision International

Are you familiar with the CHW-AIM tool? I am supposing that many of you are, as it was first released in 2011 and has been widely used since then. CHW-AIM stands for Community Health Worker Assessment and Improvement Matrix, and it spells out all of the important program components that are needed for CHW motivation and success. Things like adequate training. Regular, supportive supervision. Work supplies. A balanced package of financial and non-financial incentives. Let me ask you – are these all examples of things that you yourself also need, in your own job? Chances are, you said yes! On some level, this is common sense. All workers – including Community Health Workers – need to have certain minimum conditions met in order to do their jobs. The CHW-AIM tool helps us to assess whether these important considerations are in place or not.

As World Vision has gained experience using CHW-AIM to assist Ministries of Health (MoH) to analyze and improve the CHW programs we support in over 40 countries, we have found that the same problems and issues continue to rear their heads, again and again. We hear, for example, that CHWs may only receive two or three days of training. Or that their supervisors are based in district capitals, far from the field, and the CHWs rarely see them. Or that the CHWs are not paid for their hard work or, if they are, payment is often delayed. That they run out of the supplies they need. That they often feel overworked. We hear that many CHWs eventually become demoralized and may sometimes wish that they could drop out, but the needs of their communities make them reluctant to quit.

Do these concerns resonate with you, or with the CHWs that you know? Why is it, do you think, that we aren’t always seeing the progress we wish we could see in improving these aspects of CHW programs?

As we reflected on this question during an internal workshop in World Vision, we agreed that there are certain health systems prerequisites that need to be in place, in order for the training, supervision, supplies, salary and other issues to be resolved. There needs to be adequate financing for community health in the country in the first place, for example, in order for the MoH to be able to pay for CHW trainings, supplies and stipends. There need to be sufficient numbers and capacity of human resources within the MoH in order to properly manage the CHW program and supervise the CHWs. The overall health supply chain needs to function well, and reach the “last mile.” These and other prerequisites categorize into the seven well-known community health system “building blocks.” We decided that we need to look at those first, as they relate to the CHW program, before we look at CHW-AIM. We developed a tool that we call Health Systems Assessment and Improvement Matrix – or S-AIM – to do exactly this, and to serve as a systems-level complement to the CHW-AIM tool.

S-AIM is structured similarly to CHW-AIM. Each of the building blocks is laid out on its own page, in a matrix ranging from 1-4, with bullets that list the criteria for a health system component (building block) to score as “not enabling” (1), “partially enabling” (2), “enabling” (3), or “highly enabling” (4). World Vision conducted a comprehensive literature review to anchor the criteria in the evidence and asked a team of external experts to review and provide feedback on the tool.

We then tested S-AIM in two workshops – one with the national Ministry of Health in Uganda, and one with the Machakos County Community Health team in Kenya. We decided in these workshops to use both CHW-AIM and S-AIM and, together, the two tools resulted in comprehensive assessments of the community health/CHW programs in those countries. The CHW-AIM scores showed us those programmatic elements that were in place and those that were not in place to support CHWs, and the S-AIM tool helped us to assess the root causes – the prerequisites – related to the health system. What did we find out? Some highlights worth mentioning are the following:

S-AIM component: Leadership and governance/political will: We used S-AIM to look at various markers of leadership and governance and political will for the CHW programs: 

• Kenya has made tremendous progress in institutionalizing community health at the policy and practice level, currently having in place a Community Health Policy 2020-2030, a Community Health Strategy 2020-2025, and an Investment Case for Community Health. “Political will” for the CHW program was further demonstrated in 2023 when the newly-elected President of Kenya approved regular payment of the 103,000 Community Health Promoters in the country.
• Uganda recently finalized its first National Community Health Strategy 2022-2026 and plans are being considered for developing a corresponding Community Health Policy, and Investment Case.

Having strong policies and strategies in place is a marker of political will for CHW programs and institutionalizing and formalizing CHW programs. S-AIM lists the numerous policy, governance and leadership points that countries should consider.

S-AIM component: Information systems

• Both the Kenya and Uganda national Ministries of Health are investing in digital solutions. Kenya maintains a master list of CHWs, housed in a registry, and Uganda is in the process of completing its list. Among other advantages, CHW master lists help track training and accreditation, and payment.
• Both countries are moving to eCHIS data collection which, when fully scaled up, should result in substantially improved CHW data quality.

S-AIM component: Other

• Gaps were identified in both countries, particularly in the areas of financing for community health and supply chain functioning. The S-AIM tool aided the teams to identify priority gaps needing attention.

Comprehensive, concrete and feasible action plans were developed in both countries to address the identified gaps, with high-level MoH and implementing partners’ commitment to follow up.

Participant feedback on use of S-AIM was enthusiastic. In both countries the MoH and partners found the tool easy to use, although it was generally agreed that experts in the areas of financing, information systems and supply chain need to be present to provide input and background in order for the groups to score those categories. The bulleted criteria in the matrices were felt to be “the right ones” for assessing the health system, and participants were able to reach consensus on scores that they felt provided an accurate picture of the status of the system with regard to the CHW program. They noted that, with the scoring complete, the tool can now serve as a checklist for tracking progress.

In sum, the S-AIM tool enabled a deep analysis of the health systems conditions that affect the functioning of the CHW program in both countries. S-AIM is now ready for wide dissemination and use. The tool is aimed primarily at Ministries of Health and local and/or international partners supporting CHW programs and may be used for assessment and improvement as in the two pilot experiences, or for structuring community health strategies and CHW program design. In most cases a workshop format is recommended, ideally led by a facilitator with experience leading CHW-AIM exercises, as the two tools are complementary and share similar formats, audiences, purposes and processes.

For further information, contact michele_gaudrault@wvi.org.