Community health worker (CHW) programs remain an underutilized tool, despite decades of research demonstrating their potential for providing universal primary health care (PHC) and improving health outcomes. The following are key challenges to effective CHW programs at scale:
Despite evidence that CHWs can deliver interventions in a cost-effective way, compared to strictly facility-based PHC, CHW programs remain a significant cost to the PHC system.
In the context of constrained resources for PHC services, the implementation and scale-up of CHW programs usually relies on external funding (often fragmented across multiple donors, and individual diseases; see figure below). According to a study from the USAID’s Center for Accelerating Innovation and Impact (CII) and the Financing Alliance for Health, around 60 percent of the current funding for CHW programs in sub-Saharan Africa comes from donors.
Given this restricted funding, programs are often designed with volunteers or performance-based incentives for CHWs. The above mentioned study estimates that less than 40 percent of CHWs in sub-Saharan Africa are salaried. This arrangement makes the programs more affordable, but also more fragile and prone to becoming a lower priority for the health system. When funding lapses, such programs are often dismantled.
Often, countries have a patchwork of CHW programs managed by various NGOs, each focused on its own narrow list of health challenges, and with different remuneration, training, and performance standards. Such inefficient fragmentation scatters limited resources and creates both redundancies and gaps in PHC. Additionally, it poses challenges for government ownership and program management.
Moreover, the differences in CHW skills, services, and training between the various CHW cohorts working in a single community can be confusing to patients, and decrease their trust, leading to less demand for services.
In addition, fragmentation undermines the critical connection between CHWs and facility-based PHC systems. Data in such fragmented systems is generally not shared across the health system and therefore does not contribute to building robust and effective health management information systems. Bangladesh is an example of a country that has leveraged the work of NGOs and is working to minimize fragmentation.
Designing CHW programing is extremely challenging. First, there is no one-size-fits-all model that will be effective in any geography. Second, despite multiple studies and recent WHO guidelines, we still do not have precise information on how to best design critical program elements to optimize impact, scalability, and sustainability.
While the building blocks of CHW programs have already been identified, their design have to be tailor-made to address specific health system infrastructure, workforce structure, task-shifting and other health policies, as well as fiscal space, disease burden, and cultural/social norms in each geography. In addition to these technical challenges, financial and political factors can often influence program design, undermining performance and long-term sustainability.
Even if the initial program design has taken all the important local factors into account, it has to be adapted based on program performance, a difficult task for any organization supporting CHW programs. Few implementing organizations, including governments, have the capacity to regularly monitor performance data and tweak program design, when needed, to improve performance.
Health systems, particularly in low- and middle-income countries, suffer from low performance. This is as true for community level interventions as it is for facility-based care.
Moreover, while there are many examples of high-performing small-scale CHW programming, there are few examples of high-performing large-scale CHW programming. There are even fewer studies that outline the processes and practices, and the context and supporting systems that enable countries to implement high-performing large-scale CHW programs.
Scaled CHW programs often underperform, faltering in the face of implementation challenges such as:
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TRAININGProviding quality and uniform training for CHWs at scale, often across an entire country, can be challenging. When CHW training programs are scaled, consistency and quality often suffer. Training programs for CHW supervisors face the same fidelity hurdles. |
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SUPPLIESOperational challenges often undermine efforts to supply CHWs with the basic supplies needed to do their work. Consistently and effectively supplying frontline workers in the most remote communities continues to be a key challenge. |
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PERFORMANCEThe performance of CHWs, particularly those who are unpaid or poorly paid and those who are minimally supervised, is often subpar. Ensuring CHWs are effectively supervised in remote and low-resource settings continues to be one of the most critical challenges. Often, there is little or poor data collected on CHW performance. What data exists is often not harnessed consistently to optimize performance management. |
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HIGH TURNOVERHigh CHW turnover can pose a financial and logistical challenge, given training costs and the time to recruit and train new CHWs. Turnover is often the result of low or no pay, unrealistic responsibilities, and poor supervision. |
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CHW SELECTIONCHWs are often not vetted by the community and instead selected based on their political connections. |
The World Health Organization has developed guidelines to optimize the design and performance of CHW programs1, providing recommendations across the most important CHW program design elements (CHW selection, training, remuneration and supervision, community engagement, etc.). The monitoring and accountability framework for these guidelines has grouped a set of prioritized indicators (the “5-S”) which need to be part of a coherent strategy: selection, skills, supervision, salary, and supplies:
WHO guidelines to optimize CHW program design and performance
1. 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.
2. 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.
3. 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.
4. 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).
5. Supplies
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.
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1
WHO guideline on health policy and system support to optimize community health worker programmes. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. http://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf.. Accessed January 30, 2019.