Our evidence-based recommendations are intended to help other CHW programs achieve success at scale. These recommendations do not aim to create a one-size-fits-all approach to designing CHW programs. Rather, they reflect our understanding that what makes CHW programming so valuable is its flexibility to address the needs and context in which they are situated. There exist a variety of program models, each for a different setting, that optimize CHW effectiveness. There is no ideal setting and no ideal programmatic model. In fact, our research indicates that adapting CHW programs to local contexts is critical. At the same time, there are certain policies and strategies that can help leaders design and develop effective CHW programs to suit their specific context and health priorities.
Leaders seeking to design or strengthen CHW programing to achieve optimal health outcomes should consider the following five universal recommendations. In this section, context-specific findings, which may – under certain circumstances – provide important guidance to improve program performance and health outcomes, can be found.
Recommendation 1
Invest in systems, not just the services CHWs deliver
Each of the Exemplar CHW programs we investigated followed a set of best practices identified in the recently released WHO guidelines to optimize CHW programs. These guidelines, along with insights from Exemplar CHW programs, highlight investing in five foundational systems components (also sometimes referred to as the “5-Ss”), regardless of contextual factors:
- Selection: strong engagement from the community contributes to more effective CHW programs. CHW selection systems are rooted in the communities they serve, and favor women. Strong CHW density (ratio of CHWs per population) can be sufficient to equitably provide coverage for the entire population.
- Skills: the training system, which includes pre-service training and continuing education, is standardized at the national level. Minimum standards are set for skills to be acquired upon completion of the training. All CHWs satisfactorily complete competency certification processes prior to beginning their work as CHWs.
- Supervision: a robust supervision system, in which supervisors - often frontline clinicians like nurses - are trained to provide CHWs supportive supervision on a regular basis strengthens performance and improves outcomes.
- Salary: strong payment systems can ensure CHWs are paid adequately and in a timely manner, reducing turnover and improving CHW performance. CHWs are contracted to receive financial remuneration consistent with the job demands, complexity, number of hours, training and roles. Opportunities for salary increases are available commensurate with experience, advancement in skills, and completion of additional training (including opportunities to progress to higher-level positions in the health system).
- Supply: CHWs require a strong supply system that ensures they are properly and regularly supplied with high-quality commodities and consumables needed to deliver healthcare services.
Recommendation 2
Cultivate political will and build government-led coalitions
Health policy reform is as much a political issue as it is a technical one. Central to the stories of successful CHW programs, such as those in Bangladesh, Brazil, Ethiopia, and Liberia, has been a strong and sustained political commitment to improved health care access and outcomes. Across our four Exemplar countries, we found a common pathway to building the necessary political commitment: CHW programs were born out of long-term health challenges that were strategically identified, elevated and framed as “crises,” and leveraged by CHW program advocates to secure government support.
In each country, CHW advocates positioned CHW programs as a solution to the health challenges they helped prioritize and frame as a pressing crisis. In Bangladesh, the crisis was high fertility rates and low access to modern family planning methods, which was seen as a major impediment to economic development. In Brazil, the crisis was shocking data on access to healthcare. In Ethiopia, the lack of meaningful progress toward critical health goals was framed as a crisis. And in Liberia, poor access to health care and the Ebola epidemic provided the critical spark for strengthening an under-resourced and fragmented community health program.
It is also worthwhile noting that in each of our Exemplar countries, top national political leadership demonstrated strong long-term political commitment and championed CHW programs. This served to align officials across ministries, geographies, and levels of government and ensure financial support. Endorsement across government is critical to the launch and ongoing management of CHW programs. For example, the vocal support of top leaders in Ethiopia ensured Ethiopia’s Ministry of Education could be counted on to provide resources (including teachers) needed to train CHWs.
Recommendation 3
Harness Data to Inform Continual Innovation and Adaption
Each of the countries we identified as Exemplars took an iterative approach to their CHW program design. Their process started with a pilot to help understand the problem and test possible solutions. It continued with the launch of CHW programs that included robust monitoring systems capable of continual surveillance. Finally, they built a feedback system to harness data and inform regularly scheduled programmatic adjustments to ensure programs adapted to improve performance quality and expanded or shifted to serve changing needs.
Perhaps the best example of this is Bangladesh’s CHW expansion, which went from a focus on access to modern family planning in the 1970s, to incorporate child health in the 1980s, to add maternal health in the 1990s, and universal health care thereafter. In Ethiopia, monitoring systems identified the need to increase CHW services and increase training to ensure the program continued to meet changing local needs.
Recommendation 4
Secure Community Support
What makes CHW programming unique is its strong connection to the communities served. The strongest CHW programs cultivate community engagement and recognize the community is not just a passive recipient of aid. The high-impact CHW programs we examined rely on communities to select CHWs, provide space or construct and maintain offices for CHWs, provide supervision, and deliver program support, such as mobilizing demand for health care.
Recommendation 5
A Problem-driven Approach to Program Design
All CHW Exemplar countries used a problem-driven approach to program design. This means they designed their program as a tailor-made response to specific health system challenges in a given geography. The following three steps provide a broad outline of the problem-driven CHW design process:
- First step: clearly and narrowly identify the priority health problem the CHW program should address. (For example, is the problem poor health indicators? What regions or segments of the population are most affected? What health indicators capture the problem?)
- Second step: analyze the origin of the problem. Understand institutional dysfunctions, stakeholder interests, and other structural factors. Understand if the problem is supply (i.e., no access to health care providers or health centers) or demand (i.e., low-health seeking behavior) or a mixture of both. Why does the problem exist?
- Third step: Identify what CHW program design elements can help solve the problem identified. Specifically, how might a CHW program be tailored to address the specific country context? The following table demonstrates how each CHW program identified as an exemplar was designed to address a specific problem.
CHWs work in the communities where they live, and bring health services to their neighbors, linking communities to the facility-based primary health care (PHC) system through referral networks.
| Ethiopia | Liberia |
|---|---|
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Ethiopia brought health services closer to the population by building a network of health posts, each staffed by two female CHWs (~4.9 CHWs per 10,000 population). Ethiopia later incorporated a network of ~three million part-time volunteers, the Health Development Army Volunteers, who model and promote healthy behaviors in the communities where they live. |
Liberia’s CHW model places one CHW in each hard-to-reach village (~21 full-time equivalent CHW per 10,000 population), deliberately targeting those communities that have difficulty accessing PHC facilities. |
CHWs are trusted community members that bring services closer to the population, lower the effort needed to access care, and help communities understand the value of PHC services.
| Liberia | Brazil | Ethiopia | Bangladesh |
|---|---|---|---|
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Liberia’s CHWs proactively visit each home in their communities to maximize opportunities to provide care and ensure the population benefits from the full range of PHC services. |
Brazil’s CHWs proactively visit homes to identify health needs, promote healthy behaviors, and help the population access a full range of government services, including the facility-based PHC network. This high-touch model can be very effective in contexts with a high burden of non-communicable diseases, such as diabetes. |
Ethiopia deployed Health Development Army Volunteers to improve access to PHC services and increase healthy behaviors. These volunteers complement Ethiopia’s Health Extension Workers who work at health posts and also in the community. |
In Bangladesh, trusted CHWs promote services that were previously unavailable and may have been unfamiliar to those in rural and remote communities. Services include family planning, institutional deliveries, immunization, and others. |
Because they are both trusted by the community and closer to it, CHWs can identify outbreaks, maintain community member trust in the health system when a crisis arrives, and ensure PHC services continue to be provided.
| Ethiopia, Liberia, Bangladesh |
|---|
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In Ethiopia, Liberia and Bangladesh, where there is a high burden of malaria, pneumonia, and diarrhea, CHWs can identify cases early to improve outcomes, provide care for non-severe cases, and refer patients with signs of severe disease. |
In the context of constrained human resources, CHWs are a cost-effective tool to increase the availability of quality care, particularly in remote areas.
| Ethiopia | Liberia |
|---|---|
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Ethiopia designed its CHW model to deliver critical primary health care services despite a dramatic shortage of nurses and other trained personnel, particularly in rural areas. While the country was eventually able to increase the number of nurses, CHWs could be trained faster and be deployed to their own remote and rural home communities, where it is often hard to retain other, more highly trained, health workers. |
Liberia trained individuals from hard-to-reach communities to serve as CHWs, to address the shortage of nurses and the difficulty of deploying them to remote rural areas. |
| Liberia |
|---|
Given its recent history of the Ebola outbreak, Liberia designed an epidemiological surveillance component into its CHW platform that tracked the most important infectious diseases so CHWs could quickly identify and respond to outbreaks. |