While each of the Exemplar community health worker (CHW) programs have maintained scaled impact, they continue to experience challenges. Common, recurring challenges, are outlined below.
Financing
Long-term financing is an issue not only for low-income countries like Liberia, where about half of the funding for the program's next five years has not yet been committed. Securing long-term financing is also difficult for middle-income countries like Brazil, which has seen a wave of political instability and financial austerity following the 2014 financial crisis. Long-term funding in Brazil has been jeopardized by the fact that many wealthy municipalities in Brazil have never implemented the Family Health Strategy and much of the middle class, which is an important voting bloc, does not use its supported CHW program. This lack of support from two key constituencies increases the financial precariousness of the program. Ensuring universal coverage and usage is, in this way, tied to long-term financial sustainability.
Implementation across all settings
Although CHW programming is aimed at improving access to care, achieving universal access can be tricky. Brazil’s CHW program is implemented by municipalities. Wealthier municipalities often never implement the program, which means low-income people living in wealthier areas often have no access to the program. In other countries, there have been challenges to replicating programs across all geographies and communities. In Ethiopia, there have been struggles to implement its CHW program in pastoralist and urban communities. Liberia is still considering how to best implement its program in peri-urban settings.
Quality of care and productivity
Quality of care and productivity remain an issue, particularly in geographies where there is inadequate training, poor supervision, or high CHW turnover. For example, in Bangladesh, studies have found the vast majority of government CHWs do not have the necessary skills to deliver the essential service package and the majority of clinics lacked the appropriate equipment and drugs they needed to meet the supply needs of CHWs. Such deficiencies undermine confidence in CHW cadres.
In Ethiopia, the government has worked to establish a career ladder for CHWs that improves motivation and retention, which in turn improves quality of care.
Program management and consistent strategy
Good program management is challenging in the health sector, and the management of CHW programs is not an exception. Government capacity to manage program implementation can change over time and across geographies within a given country. Some municipalities, provinces, or counties may have higher capacity than others. Program fidelity can suffer as a result of these varying management capabilities. But there are strategies that can help ensure strong program management and reduce the risk of program fragmentation.
For example, Liberia adopted a program management strategy that recognized and adapted to each county’s needs. Counties, which are charged with implementing and managing the program, work closely with NGO partners. As a county capacity strengthens, its partners move into more of a support role, allowing the county to take more ownership of program management. Today, the majority of county health teams rely on NGO partners to manage their CHW programs, and the few county health teams that have the capacity to manage the program on their own do so.
Job satisfaction, CHW selection, and retention
CHW job satisfaction is critical because high rates of CHW turnover not only increase costs, but also undermine quality of care. Countries with Exemplar CHW programs have prioritized ensuring that CHWs are adequately paid in a timely manner, are well-supervised, and are not burdened with unrealistic responsibilities. However, challenges remain.
This is particularly true in Bangladesh, which reports high rates of turnover and absenteeism, and Ethiopia, where CHWs report low job satisfaction.
It is important to note that hiring dedicated and appropriate CHWs is not easy. In Liberia, there are not enough literate women in rural communities to meet the hiring needs of the program. And Ethiopia has experienced the same problem in its pastoralist communities. Ethiopia has responded by making a strategic shift away from focusing merely on retention of CHWs and instead, focusing on ensuring opportunities for CHW professional development. By building a career ladder, Ethiopia is building a pipeline of dedicated and skilled CHWs capable of serving their communities on a number of levels.