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How can research support the optimization of CHW programs?

Posted: 11 Jun, 2017   Recommendation: 1   Replies: 10

Hello all! Thanks for joining our discussion on CHW performance. I’ll offer a few brief thoughts and questions to kick us off; I am looking forward to a spirited discussion!

Community health workers (CHWs) were widely promoted as a means to provide primary healthcare in resource poor settings as early as the 1978 Alma-Ata Declaration [1]. A series of reviews in the late 1980s and early 1990s, however, found that large-scale CHW programs often failed to replicate the success of smaller community-based programs [2-7]. Since this period, rigorous evidence accumulated on the efficacy of CHWs to deliver assorted health interventions [8-11]. Yet the most recent evaluations of national-scale CHW programs remain unfavorable [12-14].

It is difficult to assess on the basis of such evaluations, however, whether a given CHW program did not achieve the desired outcome because (i) such programs do not work, (ii) a given program was not implemented properly (type III error), or (iii) the CHW program design was not yet optimised to achieve maximum effect (e.g. via the best or most efficient combination and dose of intervention components) [15-18]. Given this,

- How should we measure the quality of CHW programs? What might a CHW quality standard or checklist look like?
- What evidence exists about improving CHW performance? (I have attached a few examples of relevant research here: Ashraf and colleagues on CHW recruitment, De Renzi and colleagues on mobile-supported CHW supervision, and Andreoni and colleagues on CHW incentives )
-What questions remain unanswered and what type of research might help answer them?

Attached resources:



Amy Madore Replied at 11:26 PM, 11 Jun 2017

Please see below for the citations that correspond to Madeleine's initial post. Thanks for kicking off the discussion and sharing these resources, Madeleine!

1. World Health Organization, Declaration of Alma-Ata, in International Conference on Primary Health Care. 1978, World Health Organization: Alma-Ata, USSR.
2. Berman, P.A., D.R. Gwatkin, and S.E. Burger, Community-Based Health-Workers - Head-Start or False Start Towards Health for All. Social Science & Medicine, 1987. 25(5): p. 443-459.
3. Frankel, S., The community health worker: effective programmes for developing countries. 1992: Oxford University Press.
4. Heggenhougen, K., et al., Community health workers: the Tanzanian experience. 1987: Oxford University Press.
5. Walt, G., CHWs: are national programmes in crisis? Health Policy and Planning, 1988. 3(1): p. 1-21.
6. Gilson, L., et al., National community health worker programs: how can they be strengthened? Journal of public health policy, 1989: p. 518-532.
7. Walt, G., Community health workers in national programmes: just another pair of hands? 1990, Milton Keynes, UK: Open University Press.
8. Kredo, T., et al., Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy. Cochrane Database of Systematic Reviews, 2014. 7: p. CD007331.
9. Lassi, Z.S., B.A. Haider, and Z.A. Bhutta, Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews, 2010. 11. Available at:
10. Lewin, S., et al., Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews, 2010(3). Available at:
11. Okwundu, C.I., et al., Home- or community-based programmes for treating malaria. Cochrane Database of Systematic Reviews, 2013. 5: p. CD009527. Available at:
12. Munos, M., et al., Independent Evaluation of the Rapid Scale-Up Program to Reduce Under-Five Mortality in Burkina Faso. American Journal of Tropical Medicine & Hygiene, 2016. 94(3): p. 584-95. Available at:
13. Amouzou, A., et al., Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial. American Journal of Tropical Medicine & Hygiene, 2016. 94(3): p. 596-604. Available at:
14. Amouzou, A., et al., Independent Evaluation of the integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design. American Journal of Tropical Medicine & Hygiene, 2016. 94(3): p. 574-83. Available at:
15. Borrelli, B., The Assessment, Monitoring, and Enhancement of Treatment Fidelity In Public Health Clinical Trials. J Public Health Dent, 2011. 71(s1): p. S52-S63. Available at:
16. Collins, L.M., et al., The multiphase optimization strategy for engineering effective tobacco use interventions. Ann Behav Med, 2011. 41(2): p. 208-26. Available at:
17. Hasson, H., Systematic evaluation of implementation fidelity of complex interventions in health and social care. Implementation Science, 2010. 5(1): p. 1. Available at:
18. Basch, C.E., et al., Avoiding type III errors in health education program evaluations: a case study. Health Education & Behavior, 1985. 12(3): p. 315-331. Available at:

Omur Cinar Elci Replied at 11:17 AM, 12 Jun 2017

These are highly relevant and important questions to explore. I'd like to share a brief note on monitoring and quality assurance aspect. In my experience from the Caribbean and Africa, community ownership and community members' direct involvement in monitoring and quality assurance produce the most effective and sustainable result. Efforts usually fail because either professionals/scholars keep these efforts under their control to prevent errors, or only a selected small group -usually community leaders- involve in monitoring and quality assurance activities. However, once we open seats to ALL, with strong training, guidance, and feedback mechanisms, community's perception, outcomes, and impact change significantly.

Just one example from Mozambique, a primary health care provider were failing to access the target population and blaming "Curanderios" traditional healers as a road block. Inviting curanderios to join the decision making mechanism and asking their lead as a change agents resolved the problem. Im sure there are many more examples out there. Just few thoughts.

Madeleine Ballard Panelist Replied at 12:45 PM, 12 Jun 2017

Hi Omur,

Thanks for sharing your experience. I think participatory (i.e. community ownership of and direct involvement in) M&E is a great topic to explore. An interesting resource on this--by an academic no less!--is this powerpoint (link below) by Susan Rifkin. She talks in particular about how participatory methods can be used to gauge less tangible issues (e.g. empowerment) that more common approaches to measurement may find difficult to assess.

Let me know what you think!

Omur Cinar Elci Replied at 2:47 PM, 12 Jun 2017

Thank you Madeleine, I agree it is a useful tool to connect community, needs, priorities and the capacity. One other useful tool is to establish Community Advisory Boards with a unique -and careful mixture of community members from different backgrounds, workers, farmers, professionals, leaders, academicians, and students. Such a mixture in an inclusive environment might create a great learning, involvement and empowerment opportunity. Regards, Omur

Madeleine Ballard Panelist Replied at 5:17 AM, 14 Jun 2017

A colleague just sent this resource to me and I thought I would share with the group. The PHC initiative focused on forming alignment and then collecting data for key KPIs to drive performance benchmarks and improvements. Would something similar be possible for community health?

Attached resource:

Rebecca Weintraub, MD Replied at 9:48 AM, 15 Jun 2017

Colleagues - sharing below Naimoli et al.'s thinking on the challenges countries face maintaining or improving community heath worker performance at scale.

They propose a package of four strategies for overcoming these challenges, primarily by increasing collaboration between communities and health systems:

(1) joint ownership and design of CHW programs,
(2) collaborative supervision and constructive feedback,
(3) a balanced package of incentives, and
(4) a practical monitoring system incorporating data from communities and the health system. These strategies touch on issues and opportunities being discussed across this rich panel discussion.

According to the authors, one of the challenges impeding performance improvement is that a shared, well-funded research agenda has been lacking, and "the evidence base on proven strategies to enhance and sustain CHW performance is modest" -- in part, because "researchers have not commonly raised or properly investigated questions about which interventions are most likely to improve and sustain CHW performance at scale." Would be great to hear your reflections on this perspective, Madeleine, and to hear from you and others how researchers know what kinds of studies are being conducted at a given point in time. Is there a community like this one (virtual or otherwise) where scholars and implementers can discuss ideas, challenges, research agendas, and what types of methodologies are appropriate to get at the dilemma you describe (why a CHW program does not achieve its desired outcomes)? What efforts are underway to steer, support, and strengthen research to address this dilemma?

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach

Giorgio Cometto Replied at 10:53 AM, 15 Jun 2017

thanks everyone for a stimulating conversation. In relation to the last question posed by the panelist about the knowledge gaps and the research agenda, I would like to share with you the WHO perspective:

First, while there is a wealth of research experience on the role of CHWs regarding communicable diseases and maternal and child health, there is less research on their role regarding noncommunicable diseases, which are responsible for an increasing proportion of the global burden of disease. Given that many countries are going through an epidemiologic transition, it will be critical to define research and policy priorities, with flexibility to allow countries to adapt them to their population and health system needs over time.
Second, more attention should be paid to cross-cutting enabling factors, for example, education, accreditation and regulation, management and supervision, effective linkage to professional cadres, motivation and remuneration, and provision of essential drugs and commodities.
Third, there is a research gap in understanding how to ensure the sustainability of programmes supported by CHWs, by using innovative national planning, governance, legal and financing mechanisms.
Fourth, previous research experience on the role of CHWs represents a mix of varying degrees of quality, while the emphasis of future research must be on scientific rigour to strengthen the evidence base for policy and practice.
Finally, it is important to avoid too narrow a disease- or intervention-specific focus to CHWs’ research. There is a need to investigate not only the effectiveness question (what works), but also the contextual factors and enablers (how, for whom, under what circumstances). Getting an answer to such policy questions will require research that uses mixed methods.

It is critical to also put research and evidence to good use. WHO is actively engaged in bridging the know-do gap in terms of CHW policy, planning, financing and management decisions, with ongoing work to develop guidelines to assist Governments and other stakeholders in optimizing performance of CHWs programmes as part of a holistic health workforce and health system approach

PETER KITONSA Replied at 3:48 AM, 16 Jun 2017

Thanks a lot.


Dr James

.... A sick person's pain takes precedence over my fatigue, someone else's
fever is more important than my sense of overwhelm!

Madeleine Ballard Panelist Replied at 1:04 PM, 16 Jun 2017

Hi Rebecca and Giorgio,

Thank you. I would second the entirety of Giorgio's comment. The suggestions from Naimoli et al. in some ways illustrate these deficits: in existing evidence of CHW efficacy, insufficient operational detail is provided for many of the elements identified as critical to the success of the programs (e.g. "collaborative supervision"). For example, the following highly cited trials (Agrasada et al., 2005; Haider et al., 2000; Rahman et al., 2008; Rotheram-Borus et al., 2014) identified “supervision,” “training,” and “selection” as critical to the success of the CHW-delivered intervention they were testing, but none defined the terms. As a result, it remains unclear which approaches work (e.g. type of supervisor, frequency of supervision, intensity of auditing) or how they are best implemented.

As Giorgio said, for health issues where CHW interventions have already demonstrate clear and consistent benefits (e.g. IMCI, MNCH), the focus of new research ought to shift from efficacy ("does it work") to optimising public health impact ("how")—i.e. understanding what CHW or programme characteristics enable or mediate effects (see: Collins et al., 2011 on the MOST Framework & component selection experiments). Such studies could be used to refine existing theories of CHW performance (e.g. as you mentioned Naimoli et al., 2014, or Kok et al., 2014; etc.)

I do not have a good sense of how or by whom this research is being steered (aside from WHO and existing informal collaborations). Others, please share! Particularly in a context where, at the behest of certain donors, RCTs have recently been used in some cases to "certify" that a particular "branded" NGO program "works" (rather than generate generalisable knowledge) there is an urgent need to extend the thought leadership and coordination Giorgio/the WHO are providing.

Kenneth Maes Replied at 4:52 PM, 16 Jun 2017

Thank you all for this discussion and the shared resources – I find them very helpful. I’m particularly interested to see the powerpoint from Susan Rifkin.

On the topic of the role/value of research, I would like to share with you a brief overview of the CHW Common Indicators Project that began a couple years ago with the Michigan Community Health Worker Alliance and has since grown to include nearly 50 people communicating across 10 US states. The main aim of the CHW Common Indicators project is to develop, recommend, and help scale up the use of a list of process and outcome metrics that every CHW program in the U.S. should use to evaluate CHW impacts at multiple levels (individual, CHW, program, population, policy). The Project is ongoing and still has a lot of work to do, but we have developed a consensus on a list of constructs to measure, and have begun pulling together resources to know how/if they are already being measured by folks in the US (and globally). For more information, visit this website: Or, please contact me (), Leticia Rodriguez-Garcia (), and/or Noelle Wiggins ().

I’d also like to re-frame the initial question of how research can support the optimization of CHW programs. The last several years have seen the publication of a growing number of studies of CHW impacts. Much of this research adopts a human resources mentality—a research modality that responds primarily to the interests of CHW employers, donors and policymakers, who tend to see worker retention and productivity as crucial cost-effectiveness issues. In this approach to research, CHWs are treated as individuals with certain motivations and levels of productivity shaped by various financial and nonfinancial incentives and other factors. The research goal is generally to test and identify a cost-effective mix of intrinsic and extrinsic workforce incentives and qualities for a given time and place.

Though the knowledge generated by this kind of research is certainly of value to policy makers and other stakeholders, my experiences with CHWs illustrate the limitations of research that adopts a human resources mentality and thus leaves out so much that matters to the processes and outcomes of CHW programs. The outcomes of CHW programs depend upon much more than individual CHWs performing quantifiable tasks in response to a certain set of incentives and recruitment messages. In some times and places, they are not just individual laborers seeking improved health outcomes for individuals; they become parts of collectives who seek changes in policy, social norms, and relationships, changes that impact broader population wellbeing in probably a multitude of ways. These kinds of social and political efforts and impacts are not easily quantifiable and are generally invisible to studies that adopt a human resources mentality. They are nevertheless important to CHWs and crucial to the functioning of CHW programs, and need to be understood.

I'm an anthropologist, so of course I feel strongly that ethnographic and mixed methods research is highly valuable. In this case, ethnographic research is needed to illuminate and explain the varied ways in which CHWs now and in the future pursue their desires to improve their own lives and job conditions, shape policies and the practices of other stakeholders, and address what they recognize as unfair and unjust—individually and through processes of collective organization and alliance-formation. Ethnographic work will also be valuable if it shows how supervisors, programmers, and donors react to the efforts and attempts of CHWs and their allies to advocate for and pursue their interests. By making known the interests and tactics of CHWs and their hierarchies and webs of stakeholders, ethnographic work can ultimately contribute to the formation of better dialogue between these varied actors, and thus to the establishment of stronger and more effective therapeutic alliances.

I also want to emphasize the need for self-reflection on the part of academic and professional researchers, about the ethics of “climbing down from the ivory tower” only to partner with relatively high-powered health policy makers and CHW employers. These actors tend to hold themselves accountable primarily to donors, do not necessarily share the interests of CHWs, and often aim to extract the labor of CHWs in more cost-effective ways. By ethnographically studying the entire hierarchy of workers, professionals, and donors, and by actively encouraging the participation and leaderships of CHWs themselves in research, researchers can help reduce or at least avoid reinforcing problematic inequalities and relationships between a class of laborers who are incentivized, directed, supervised, and researched, and a class of policy makers and experts who make key decisions, receive salaries not necessarily determined by cost-effectiveness analyses, and avoid becoming objects of study. Reducing such inequalities, I think, can further contribute to the establishment of stronger alliances between CHWs and other stakeholders, and thus to more effective programs targeting health equity.

Sorry for the long post!

Thank you!
Kenny Maes

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.