By: Carolyn MacDonald, PhD, Nutrition Director, World Vision International
As part of the ‘Symposium on CHWs and Their Contribution Towards the Sustainable Development Goals’ Makerere University (Uganda), CHW Central, Nottingham Trent University (UK), and World Vision are supporting a series of interviews with academic leaders and experts in international health development and delivery fields to provide their vision of the future of CHWs in a new light.
We will explore: How can CHWs create lasting impacts in the era of the Sustainable Development Goals? What steps need to be taken to scale up, empower, and create changes within in our global workforce?
The interviews will be posted on CHW Central over the next weeks as part of the preparation for the Symposium taking place from February 21st-23rd in Uganda. Past interviews will be posted on the CHW Hub.
Read our sixth interview with Carolyn MacDonald below.
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Personal Bio: |
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Interview Questions:
What is your vision of how ‘tomorrow’s CHWs’ will contribute to Goal 2 in the SDGs era?
Tomorrows CHWs need to understand that almost half under five mortality (45%) is due to malnutrition, so they will understand how fundamental nutrition is to health and survival. As a result, they will dedicate about half of their time to support nutrition interventions. There are a number of different cadres of CHWs, and while a few countries have CHWs that focus specifically on nutrition, most countries’ CHW’s are primarily health focused. Tomorrows CHWs need to put a lot more emphasis on supporting nutrition interventions if we are to achieve sustainable development goal 2, shifting from health to an increased focus on nutrition. CHWs will have an understanding that the underlying causes of malnutrition are complex, requiring a complex multidisciplinary response. This will translate into practical actions in their jobs. In addition to tasks traditionally associated with CHWs (e.g., promoting immunization, folic acid, bednets, ORS for diarrhea), tomorrow’s CHWs will have basic competencies in nutrition such as supporting new mothers with breastfeeding, accurately measuring children’s weights and heights, using MUAC, interpreting growth curves, and giving appropriate feedback to the caregiver based on immediate causes of malnutrition. But beyond that they also need to recognize and identify the underlying causes of malnutrition in the contexts in which they work. Training on the underlying causes of malnutrition need to be in the curriculum of CHWs, so that they can link households in a multidisciplinary approach to improving nutrition. This could mean linking families to support services for improving access to diversified diets, local foods, improving food security (e.g., through raising small animals), clean water, sanitation and hygiene, in addition to health services. CHWs will link with other actors in their districts like agriculture extension workers, health workers, social protection, water and sanitation. Then, to go the next step – CHWs will engage in monitoring community prevalence of malnutrition, reporting to higher levels and advocating for change. Tomorrow’s CHWs will monitor and advocate for reductions in prevalence of malnutrition in their communities, similar to tracking prevalence of diarrhea, malaria or other illnesses. Tomorrow’s CHWs will also have supervisors that understand the need for a multi-disciplinary approach to good nutrition and health. Given the current limited formal training on nutrition for most health professionals, health supervisor’s training, like that of CHWs, will need to be delivered through in-service trainings until pre-service curriculums catch-up in the area of nutrition. World Vision is currently using a blended distance education approach to strengthen nutrition capacity (http://wvi.org/nutrition/distance-learning). Supervisors will support and assess CHWs for their nutrition competencies, including supporting families and communities to improve nutrition using a multi-disciplinary approach.
The goal is has broader implications than nutrition goals in the MDG era, what significant change will this bring about at community level?
Well, CHWs need to be able to link families to other sectors and services. At the community level, there are emerging approaches for community committees. But ideally the link with local development communities would be broader than the current narrow focus on health committees, bringing that intersectoral dimension. The SDGs are also pushing those working in agriculture and food security to work together better with those working in health and nutrition, which they haven’t always done in the past. The SDGs offer an opportunity to articulate an approach where disciplines are working together for sustainable nutrition.
What specific actions can CHWs undertake to contribute to this ambitious goal, and what do they need to achieve that?
When you go to the community or health facility level – you often see wall charts of progress on improving immunization rates, and reducing prevalence of diseases. Sadly, it’s very rare to see a chart that shows the progress on reducing rates of malnutrition. While CHWs are doing individual growth monitoring, the results are often not aggregated and tracked at the district to see if they are reaching targets in reducing malnutrition. Nor do we see tracking on other WHO targets such as prevalence of low birth weight. That’s what CHWs need to advocate for at a higher level: that nutrition indicators are measured, targets set and appropriate interventions are resourced, with continual monitoring and feedback at higher levels, by those in the health department and using nutrition targets as a bridge to link with other sectors and local government. CHW training, work load and remuneration are three key barriers to adequately addressing malnutrition. One means to achieve a realistic workload for CHWs is to have additional or specialized cadres of CHWs, focusing on specialized areas like nutrition, as they have done in Malawi. So then they have time to focus on nutrition and link with a variety of sectors. Then secondly CHWs need to be adequately remunerated for their work, which is both empowering and allows for adequate provision for their families, including purchasing nutritious foods. There is some good research that SPRING has done recently on ‘How CHWs contribute to better nutrition’ and they’ve put together advocacy tools for increasing nutrition-related services that CHWs can provide: [access SPRING TOOL]. This work really shows you the diversity of the services CHWs are asked to provide: HIV, MNCH, family planning, water and sanitation, malaria, TB, immunizations. In addition, they are asked to provide nutrition services. We know that nutrition has been left out of that high work load already, so either you have to have more CHWs covering fewer clients, or have more CHWs cadres each specialized in various areas. I don’t know what the best answer is for all countries, but I do know you cannot simply continue adding to existing high workloads and expect good results, especially if the cadres are not adequately trained, supported and remunerated in the first place.
How might CHWs enable food security, diversity and quality at family and community levels year round?
First of all CHWs need to measure nutrition indicators at the household level and/or facility level – “what gets measured gets done”, so collecting information on the WHO’s 6 global nutrition targets, and including additional indicators on the dietary diversity score, and in some case anemia in under five children, (where contextually appropriate), is critical. Few if any nutrition indicators are currently being collected, so that’s a key action. Not all indicators need to be monitored every month, but they can and should be assessed periodically, so that appropriate actions can be taken. The health sector and CHWs don’t need to collect all nutrition-related indicators, but do need to work with other sectors to aggregate and monitor indicators, along with communities and family members to improve diet quality and diversity. Secondly they can work with local influencers, like grandmothers, more intentionally and use some innovative approaches. CHWs often have the tendency to deliver a package of key messages to everyone without ever asking questions and understanding local/family contexts; without perhaps recognizing that it’s the older women who typically define nutrition practices like pregnant women’s diets and infant and young child feeding practices. CHWs can take advantage of the family connection and work with them in different ways, not seeing them as obstructers, but appreciating them and dialoguing around changes. World Vision, in partnership with the Grandmother Project and Emory University, have found the ‘Grandmother Inclusive Approach’ to be effective in improving maternal diets; even birth weights, as well as children’s diets.
Then, there’s Positive Deviance Hearth approach: CHWs are closer to the community but need to take time to understand what’s being consumed and what’s locally available. They can identify what families with well-nourished children year round are doing currently to get through the lean seasons, and then they can feed that information back to those families with difficulties. Also, during the dry seasons when there are severe food shortages, CHWs are able to identify and support families needing to access social protection measures and food assistance. Lastly, tomorrows CHWs need to be engaged in local level advocacy, advocating for nutrition activities and services that are necessary. That could be social protection, food access or local agricultural support for increasing diversity of diets and access to animal source foods. Agriculture traditionally tends to focus primarily on increasing yield of staple crops without considering the need for good nutrition, so CHWs can work with local farmers to advocate for agriculture support that will improve diversity of diets and household’s nutrition.
What about social protection systems for nutrition, how can CHWs work best in ensuring protection for the most vulnerable families?
There isn’t a one-size fits all solution here, and it very much depends on communities’ resources and what governments are able to provide. But I think that this has to be included in pre-service training, understanding how to identify vulnerable families, including what services can be accessed and at what levels of need/vulnerability. In Sri Lanka for example, World Vision’s ‘Graduation Approach’ includes a wealth ranking, together with nutritional assessment/ranking, and the government has quite good social protection services with which vulnerable families can be linked. So a family could access, for example, a cow which can be a source of food (milk), manure for agriculture, or source of income. World Vision couples government social services with economic development supports and nutrition programs like the Positive Deviance Hearth, to help families develop tailored solutions for ‘graduation’ from poverty and malnutrition. These supports/programs may be available but often CHWs are not aware of them. In terms of identifying and mobilizing families to access social protection, CHWs can make the connection, but I don’t think that it is possible to put all responsibility on their shoulders. I think this would be more the role of their supervisors or managers, or the community level committees and their role in the community to take on aspects of mobilizing and advocacy for social protection. Some social protection systems have unintended consequences such as those which are food-for-work, so mothers and fathers are away from their children all day, which causes significant challenges for the families. So CHWs need to be aware of some of the unintended consequences, and making sure social protection has a positive impact.
How do you think the need for nutrition programming might be during the next 15 years, and how might this affect CHWs?
It goes back to the multi-causal nature of malnutrition, the underlying causes are varied and will be changing over time. Improvement in nutrition won’t be achieved without significant investment in a broader nutrition-sensitive programming. CHWs need to think and act much more broadly than the health sector to support households, and consider the cross sectoral links – agriculture, employment, social protection, water & sanitation and education. But they don’t have time! It’s hard even for them to cover the nutrition-specific interventions. The double burden is an emerging problem for many contexts. But to prevent NCDs later in life, if you are well nourished during the first 1,000 days your risks go way down. We have to prevent, because it’s really difficult and expensive to treat diabetes, obesity, and other NCDs later in life. To both prevent and treat NCDs, the role of CHWs will be to promote and protect people’s access to healthy food choices that are affordable and reduce access and discourage poor food choices (e.g., sugar sweetened beverages).
It is going to be increasingly difficult to improve nutrition without addressing the underlying issues of climate change, which is just accentuating and speeding up the challenges for people to access nutrition year round due to the decreased production and increased costs that result. In some places where drought cycles are becoming more frequent the vulnerable households are hit the hardest, are unable to recover, and it’s a downward spiral. One of the ways World Vision is addressing climate change is through ‘farmer-managed natural regeneration’ (FMNR) of lands and forests, which has a direct link to improving nutrition. It may sound small, but in fact it is a very significant approach, reforestation through using what is already in the ground, rather than planting trees, and managed locally. When they do this, then we see more trees, more water trapped, less erosion, more timber, more diversity, the insects and indigenous sources of food come back, you can grow wider variety of crops, and there are many positive spin offs of FMNR for families. So CHWs working at the household level could have this role to raise the issues through local level advocacy and push for local solutions.
Any final thoughts and comments?
Well, thanks for the opportunity. I think that the work of CHWs is so very important, and I am happy this group is promoting CHWs because they been largely under-appreciated. Many CHWs have been undermined by inadequate training, remuneration, poor supervision and appreciation and they are the ones who are reaching the most vulnerable at the household level. There is also a huge under-investment in effective nutrition programs by CHWs. We are seeing great progress in other areas of health due to CHWs’ excellent focus on childhood illnesses, but many of the children remain undernourished. So, what we really need today and tomorrow, is to invest in strengthening CHWs’ capacity to support nutrition interventions for families and communities, both nutrition-specific and nutrition sensitive. They are key!
All CHW Visions interviews have been conducted and compiled by Polly Walker.
| Bio: Polly Walker has provided technical leadership to World Vision’s community health worker (CHW) program portfolio over the 5 years. During this time she has overseen their expansion of CHW support growing from 70,000 in 2011, to over 220,000 CHWs in 48 countries. She is the co-author of Timed and Targeted Counselling: a comprehensive course for community health workers, now operating in 38 countries. Over the last 12 years of her career she has focused on CHWs, authoring over 20 CHW training modules, designed mHealth applications used in 7 countries, written various publications on ICCM, quality assurance and supportive supervision, as well as the Core Group’s CHW Principles of Practice in 2013. Polly is known for her work as an advocate for government-led harmonization and scale-up, as well as for her work in developing innovative family inclusive psychosocial approaches to community health care. |
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Public health nurses should be actively be involved in meeting SDG 2. They should bring in real examples they meet as they work in different communities