Who’s In Charge Here? Governing Large-Scale Community Health Worker Programs

By: Anya Guyer

This is the fourth 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.

“Who’s in charge here?” can be a hard question for CHW programs to answer, particularly those that operate on the large scale. Who are the people and institutions that make decisions about running a program? How do they arrive at their decisions? And how are these decisions implemented and enforced? Things rapidly become complicated for CHW programs as they may or may not be part of the formal health system. CHWs may answer to multiple authorities including local health workers, vertical program managers and community leaders, as well as their clients and patients; and, what works very well in one area may not be appropriate in another place.

Figuring out “who’s in charge” is what governance is all about. In Chapter 4, authors Simon Lewin and Uta Lehmann use this definition for governance: “the processes and structures through which individuals and groups exercise rights, resolve differences and express interests.” They emphasize that governance encompasses actors, structures, and the interactions among these actors and structures.

Any discussion of governance has to define what, in particular, is good governance. Building on the previous definition, good governance can be understood as processes for decision-making and implementation that are fair, transparent, and consensus-oriented, and which result in programs that promote the public good and human rights. Ideally, good governance generates positive outcomes for the beneficiaries of any program.

As you may already have gathered from even just the first few sentences of this summary, thinking about the governance of CHW programs generates many follow-on questions. Governance is also a continuously ongoing process; for CHW programs the process is rarely clearly defined or linear.

To address all of this, Chapter 4 articulates four key questions about governance of CHW programs:

How, and where within political structures, are policies made for CHW programs?
Who, and at what levels of government, implements decisions regarding CHW programs?
What laws and regulations are needed to support the program?
How should the program be adapted across different settings of groups in the country or region?

In the chapter, each of these questions, along with detailed sub-questions (see Table 2, pp. 14-15 of the CHW Reference Guide), is addressed in depth, with examples and case studies from across the globe provided to make the discussion more concrete. These include short summaries from Brazil, India, and Zimbabwe. The Zimbabwe summary, for example, discusses what happened when the government-created structures that were supposed to involve communities proved not to mesh well with existing community structures. Informative tables (see Tables 3 and 4, pp. 16-27) appended to the chapter provide even more details about the governance of the large-scale CHW programs in Brazil, Ethiopia, India, Pakistan, and South Africa.

The chapter emphasizes two additional points on governance:

First, developing an understanding of the contexts—from local and national—in which a CHW program works is fundamentally important. Every community, health system, and government operates differently. A committee structure that works well in one part of India may not be able to have any influence in a different region that has different traditional authority structures. Policies handed down from a central government body may not be relevant to the challenges facing a minority community. These variations need to be accounted for in CHW programs if they hope to remain acceptable and relevant to the community they hope to serve.

Secondly, for good governance to be established and sustained, resources—notably time and money—must be made available for governance processes. Programs need to allocate resources to enable the right people to come together to engage in governance processes, including policy debates, planning sessions, communication and engagement of the beneficiary communities and CHWs, and monitoring and evaluation of programmatic outcomes. Without adequate resources for these activities, the practice of governance will be severely hampered; without good governance, a program will eventually falter.

At the end of the chapter, Lewin and Lehmann comment that, “Policymakers and other stakeholders in each setting need to consider what systems are currently in place and what might work in their context and develop a locally tailored governance approach.” This chapter provides policymakers and other stakeholders with a critical tool: a list of clearly articulated questions that need to be answered in order to answer the big question of “who’s in charge?” Governing a CHW program is complicated, but the suggestions and examples provided in Chapter 4 can help decision-makers better understand the range of options they must consider.