As described in the Exemplar CHW cross country synthesis, the most effective CHW programs take a problem-driven approach. The services each CHW cohort offers should reflect this problem-driven approach and be highly tailored. CHWs should provide services that are responsive to the highest disease burden, have the highest cost-effectiveness relative to impact, and are complementary to each other and to the services provided by facility-based primary health care providers.

The process of developing a package of services will require input from a wide variety of stakeholders across multiple governmental departments, implementing partners, communities, and donors. Furthermore, it is essential to see the creation of a package of services as just one aspect of the process of building a strong community health system.

Steps to determine package of services:

1. Understand the current package of services across all cadres of any existing CHW programs. There may be many vertical, program-based CHWs and other health volunteers providing a wide range of fragmented, overlapping services. Ethiopia and Liberia faced this situation before developing a single, integrated community health system. Mapping these existing services will help identify commonalities, gaps, and available platforms.
2. Examine the data: what are the biggest health needs among the target population? When we look at Exemplar countries, we see that they designed their community health system to address the most important health challenges in rural communities. In Bangladesh, population growth threatened to overwhelm the country’s health services, so CHWs initially provided family planning services and information. The package of services expanded as needs expanded. CHWs in Ethiopia and Liberia provide preventive and curative services for the leading causes of child morbidity and mortality, such as malaria and pneumonia. In Brazil, where the community health team addresses the social determinants of health and generates demand for services, specific programming is tailored to needs by households and communities, which are targeted based on a data-driven health vulnerability index. Each of these packages of services responds to data from national health monitoring systems of varying strength. In the absence of an existing sophisticated data collection and monitoring system, the government can leverage existing data sets, like the Demographic Health Survey (DHS) and MICS reports. It may also be useful to gather information on demand for services among the population.
3. Examine the gaps between the current health service package and the major health needs of the population. It is important to note that gaps could exist in the package of services, in implementation quality and in service coverage. For instance, if malaria is a leading cause of under-five mortality but CHWs are already supposed to be diagnosing and treating malaria. Examine whether the CHWs are sufficiently skilled, supported with supervision, appropriately incentivized to do their work, receiving the supplies they need, accepted by their community, and reaching the most at-need population.
4. Evaluate the evidence on the effectiveness of different services to address these gaps. Such evidence can include medical literature on effective treatments – WHO prevention and treatment guidelines are often helpful – and learnings from pilot tests on feasibility and cost-effectiveness. Exemplar countries all used a combination of community health pilot testing within the country and learning exchanges with other countries to identify and adapt best practices. When considering feasibility, it is important to also consider the skills, supplies and supervision that CHWs will need in order to deliver the services, and ensure that their remuneration is commensurate with their skills and workload.
5. Consider the acceptability of the potential CHW service package among the community and other health providers. There may be cultural challenges to providing certain services. In addition, it should be recognized that CHWs are one component of the primary health care system and need to be integrated appropriately. They may be able to take on tasks that currently burden nurses, midwives and other healthcare providers. This sort of task-shifting can improve health system efficiency and functioning overall.
6. Data collection and monitoring is critical to identifying and meeting changing needs. The package of CHW services should not be seen as static. The community health system will need to adapt and respond to changing health needs, as we see in Exemplar countries. For instance, Bangladesh has revised its service package repeatedly over the past forty years, from focusing on family planning, to child health, to maternal health and now to universal health care, all in response to population health needs. Bangladesh’s government uses icddr,b’s comprehensive, detailed, and long-running longitudinal data resources to ensure that its policies and programs are evidence-based and effective.

Determining the most effective and appropriate service package for CHWs is a complex undertaking, but can make all the difference.

Resources to guide health leaders include:

• USAID created a useful tool, the Community Health Worker Coverage and Capacity Tool to support planners in optimizing the service package and coverage targets.
• This checklist for health service package definition, focusing on sexual and reproductive rights, by Population Council.
• These essential package of health service snapshots from USAID’s HFG project.
• The Exemplar Research Desk can provide guidance.