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How do you design a CHW program?

Posted: 11 Jun, 2017   Recommendations: 2   Replies: 13

The answer to this question could be incredibly long, but my colleagues and I at Partners In Health (PIH) have been working for years to simplify our approach to questions like this in order to increase clarity and efficacy. In 2013, we published a CHW program framework (attached) that calls attention to 5 essential CHW program elements in an acronym as a reminder of how these elements are not only essential in themselves, but also need to be balanced among each other. In the nearly half decade since we made this framework, we have come to simplify this approach even further in 5 essential questions that help achieve this goal:

1) What tasks is the CHW going to do, and what do these tasks add to the goals of all the partners, which could include the health system, the community, NGOs, etc.?
2) Are you choosing the right people to do those tasks?
3) Are you training the CHWs well enough to do the tasks?
4) Are the incentives balanced with what is being asked of the CHWs?
5) Are the CHWs supported adequately, including the right level of supervision, management, and even mentorship?
 
These questions will not cover all questions possible for a CHW program, but we hope that with their simplicity, we can all start to get on the same page about what needs to come together to make a CHW program truly great. When CHW programs function superbly, they often have smart answers to all of these questions, and the answers will fit together with an eye for design befitting the best start-up. When programs go wrong, you can often root out the problems by systematically going through these questions to find the imbalance. Here is an example of some of the most common errors in CHW program design:

In the effort to appease the many different clinical priorities of various partners involved (especially powerful members of the health ministry, donor priorities, NGO influence, etc.), the CHW is given a large list of tasks that amount to a challenging and full time job. Political pressure demands that this be extended to all citizens, but insufficient funding leads the program towards ratios of CHWs to clients that are too high, salaries that are too low, and support structures that are too little to actually carry the weight of the demand. Limited funding also leads to investments in the CHW program without concurrent investments in the larger health system, which only isolates the CHW when confronted with difficult cases. They are now sent out into the world as “mortality reduction agents,” but they are crushed by the workload, abused by their lost earning potential, and isolated because they have no network through which to refer patients. The program suffers, and despite the money spent, there is little return on investment.

The need for increased financing is primary (see the work of The Financing Alliance for Health, http://www.financingalliance.org, as an example). As this financing comes in, however, it has to be spent wisely. For the case above, this might mean: decrease the number of tasks; decrease the ratios; increase the salaries for the CHWs so that they have more time to spend on the work; increase the supports so that the CHWs are more efficient in the limited time they have.
 
Each of these options has trade-offs, so the decisions are not always easy to make. For example, decreasing tasks may mean that some patients will suffer because their disease didn’t make the cut. Program improvements, such as decreasing ratios or increasing salaries and supports will certainly help but they will also increase budgets, which will put more pressure on the need to increase financing. There are no easy answers, but it bears pointing out that the decisions one makes here say a lot about the ideology driving those decisions. If you believe health is a human right, and that equity is not only morally right but also a smart investment for a truly sustainable future, then you do everything you can to give CHWs a good, useful, paid and doable job so that they can lend their genius long term for the benefit of those who need it the most. For me, the main question is whether we're going to actually give them that chance.

Attached resource:

Replies

 

Nadene Brunk Replied at 9:47 AM, 12 Jun 2017

Is it feasible to train CHW's to work locally on a specific health issue, when there are many health issues in the community? For example, if prenatal care is only available monthly, and CHW's are trained to take blood pressures weekly on all at risk women in the community, does the training specify that they do not have expertise in anything else? Or is it better if the training of CHW's is generic and covers a variety of health issues?

BOLATITO AIYENIGBA Replied at 10:43 AM, 12 Jun 2017

Thanks Daniel for the well articulated issues raised. The limited fund available for donor funded program, the lack of sufficient contribution from host government and the demand for quick results by the donor do not allow the luxury of integration and holistic approach to CHWs-led interventions in developing nations.
It is a painful truth and the solutions may be beyond us on this platform. I am however looking forward to learning this week. Never say never!
Regards

GHDonline Team Replied at 1:49 PM, 12 Jun 2017

Hi all,

This conversation is off to a great start. Thank you, Daniel, for describing your approach to CHW program design and for sharing the 5-SPICE framework. The Penn Center for Community Health Workers' IMPaCT model compliments this framework quite well.

Some key features of the IMPaCT model include:
- Patient-centered model offering tailored psychosocial support
- Designed independent of a particular condition or location, meant to be adaptable
- Patient input was integral to the design process, which began with the question "What do patients want?"
- Emphasis not only on training of CHWs, but also on hiring the right people to be CHWs
- CHWs must share some aspect of "life experience" (such as language, race, ethnicity, or community residency) with the population with whom they work
- CHWs are based in a clinical setting and integrated into a clinical care team, but operate mostly in the community
- The model includes a digital database that integrates patient's medical information with the CHW's reports, and is accessible to all members of the care team

I am looking forward to the continuation of this conversation over the coming days!

- Claire Donovan

Attached resources:

Daniel Palazuelos Panelist Replied at 12:23 AM, 14 Jun 2017

@Nadene Brunk "Is it feasible to train CHW's to work locally on a specific health issue, when there are many health issues in the community?... Or is it better if the training of CHW's is generic and covers a variety of health issues?"

This is a really important question. Should CHWs be specialists or generalists?

The short answer: there is no "one-size-fits-all" approach to CHW involvement. CHWs can be either specialists or generalists depending on what is needed based on the burden of disease, and what the other parts of the health system are doing.

The long answer: behind the answer to this specific question is the larger issue about what the CHWs' efforts provide to the larger care delivery structure. A model that we've found helpful at PIH to help structure our thinking on this is the Care Delivery Value Chain (see article link attached). It was developed to map out the complex processes and interventions that must occur in order to achieve a high value outcome, which is the best possible clinical outcome for the lowest possible cost. A sample value chain would consider these categories: prevention, early detection, initiation of treatment, on-going care, care for clinical deterioration, end-of-life care.

The CHW can provide support for interventions all along the value chain. To use your example: a CHW working in maternal health can find pregnancies early, channel patients to antenatal care, support pregnant women retention in care, support women as they start birth by helping with transport to birthing centers or maternal waiting homes, emotionally supporting mothers during the birthing process, supporting the mother and newborn as they head back home, and doing regular home visits while the child is young to be sure mother and child are both okay.

Please notice that the CHW abilities here are all invaluable for a good outcome, but not sufficient by themselves. Doctors, nurses, midwives, surgeons, lab techs, and pharmacists will all be necessary also. Many talk about "task sharing" when it comes to CHWs, but the sad truth is that many CHWs are often assigned tasks that no one wants to do, what has been called "task dumping," and then they are abandoned in the field to do the impossible task of becoming the health system where there is no health system.

If a CHW is a "generalist" in the sense that they get assigned a million random tasks that no one wants to do, then I would argue that this is a bad way to include them in a health system. If a CHW is focused on a variety of tasks that provide value to what a team is doing, and all the team members support and appreciate what everyone else is doing, then the CHW is set up to truly provide value as a generalist, even if it is for a single disease.

Attached resource:

Ingrid Schoeman Replied at 1:12 AM, 14 Jun 2017

Thank you for this valuable and practical approach to having effecting systems in which CHW can work. In South Africa, we often see that CHW are very passionate about helping patients. However, there is such a lack of training provided to them, and in this way they don't feel supported.

Could programmes offered to other healthcare professionals such as nurses not be more inclusive and invite CHWs to attend if they have sessions for example on TB infection control?

I think outreach programmes where other healthcare workers provide input could make them feel part of a team and really increase their understanding, for instance asking a dietitian month one to discuss diabetes and TB, month 2 nurses could explain TB infection prevention and control etc.

Polly Walker Replied at 12:01 PM, 14 Jun 2017

Hi Daniel

This is Polly from World Vision - I appreciate PIH's work with CHWs, and we are recently partnering with you in lesotho towards a new national CHW programme approach. PIH have been excellent partners in the multi-stakeholder initiative. I have been working in the last 5 years to support the establishment of nationalially harmonized CHW programs, and have supported this in Ghana, Haiti, Lesotho, Kenya , Sierra leone and Mauritania. In terms of establishing CHW policy, the two most useful external tools I have found are CHW AIM assessment an improvement matrix, and also the Harmonization framework from GHWA's harmonized partner action.
CHW AIM can be used in the field to lead local or national level situational analysis and quality imporvement cycles and it capture 15 programme components including the 5 mentioned in your post but also addressing higher level issues such as referral links, health systems embedding, community engagement/involvement, program management and country ownership.
The GHWA framework for harmonized partner action and its accountability framework is more directed at governemnts trying toestablish partner coordination in CHW rpograms.

For World Vision our most useful tools for harmonizing amongst NGOS are the CHW Principles of Practice http://www.coregroup.org/storage/Program_Learning/Community_Health_Workers/CH...

which is about how to get NGOs to work together on a program - even where country leadership is strong, NGOs still proliferate fragmented programs so we need to work together better.

I also have developed a Work Load rationalisation tool which we use to demonstrate how the as-is process should be against an integrated and streamlined program with a rational workload. We recently did this in Haiti and estimated a-is process at 200 hours per week, compared to a rationalised operating model of 26 working hours full time. This feed into the healthy Families approach which is the CHW operating model adopted in Ghana, Sierra Leone, Mauritania and Lesotho. People can get ahold of these tools by contacting me -

Lastly UNICEF /MSH costing tool is a brilliant multi-stakeholder costing model for CHW programs and should be a starting point for all coalition CHW program planning!!! https://www.msh.org/resources/community-health-planning-and-costing-tool

best wishes

Polly Walker - World Vision International CHW program advisor

Ochiawunma Ibe Replied at 12:49 PM, 14 Jun 2017

Hi Polly,
I would like to affirm your response to Daniel's question and add that USADI Maternal Child Survival Program is in the process of refining an Excel based tool - Community Health worker Coverage and Capacity (C3) tool that will help in the rationalization and prioritization of the CHW workload. The tool aims at supporting National Ministries of Health establishing CHW programs address the best ways to utilize their CH workforce for impact and adapt their CH policies for feasible implementation. The tool is intended to be complementary to the Unicef/MSH Community Health and planning tool such that outputs from C3 can be fed in to the later and then costed.

Sascha Lamstein Replied at 2:57 PM, 14 Jun 2017

Daniel, thank you for raising this and for your introduction to SPICE. Polly, I love your work and the resource you have shared.

I work with the USAID-funded SPRING project, which focuses on nutrition. Recognizing that CHWs are often over-burdened, health systems are constrained, and malnutrition is a multi-sectoral issue, we believe that responsibility for the delivery of nutrition-related "services" must be shared among a range of other frontline workers and community actors. We are currently writing up our approach to engaging a wider range of actors in preparing the "recipe" for nutrition. I wish I could share with you all now, but it isn't quite done.

Also, SPRING's District Assessment Tool for Anemia (DATA) was designed to assist program managers in strengthening anemia programming - including CHW programs - at the district level.

Thank you!
Sascha

SASCHA LAMSTEIN, PhD, MS
Technical Advisor and Team Lead, Systems Thinking for Nutrition

Attached resources:

Polly Walker Replied at 5:44 AM, 15 Jun 2017

Hi Ochiawunma

Thanks for your comment... its actually something Eric Sarriot and I have been discussing before he joined Save the children, as the work load tool that he developed with Melanie for the MCSP project is very similar to the one I have. He suggested collaboration on it because I have developed a 'work load process' that can be used along side his tool. And also - Healthy Families tool has just proved to be a godsend in terms of integrating activities for the CHW - preliminary findings from Ghana say that families are responding really well. The fact that 5 MOH National programs have picked it up already is a good sign that its making stakeholders come together and agree to common goals very rapidly.

Also good to mention that World Vision technical services organisation - of which I am now a part - are opening up their huge collection of tools and materials and now providing external technical services, so we can either collaborate or we can come and train your team as well! Its early days still, but you can email me on , and you can read about the Healthy Families integration/ work load simplification approach in the link below!

Attached resource:

Polly Walker Replied at 5:53 AM, 15 Jun 2017

Thanks Sascha - I love your work too! I heard about SPRING's tools from Carolyn MacDonald when I interviewed her for the CHW visions of the future series (http://www.chwcentral.org/blog/tomorrows-chws-ending-hunger-and-malnutrition)

is this the one about CHWs roles in nutrition advocacy? I am really curious to see how we could start using this tool in World Vision, it fits extermeely well with things we;ve developed in Sierra leone for example - what we have found is the gap for CMAM services, there is often relapse of the same children and it would appear facility based CMAM doesnt always address the root causes in the home. We have developed a tool, now in the National curriculum of Sierra leone and Ghana, called Root Cause Assessment where the CHW visits post CMAM and assesses systematically the issues in the home from food security to wash and ECD, child protection, neglect, as well as the usual feeding practices. Once they've done that they can elevate the household level issues to community committees and such like using the SPRING advocacy tool but would love to hear from you how that looks in practice.

Denish Moorthy Replied at 9:38 AM, 15 Jun 2017

Hi Polly,
I lead the DATA project at SPRING Anemia team. Though the tool is not aimed at CHWs - we're looking to assist district planners from different sectors in prioritizing anemia interventions - we discovered, from our work in Ghana, Uganda and Nepal, that CHWs (and their equivalent in other sectors like education and agriculture) can and should provide important inputs to the planning process. Even though our main goal is reducing anemia (a priority for the MoH in these countries), we are aware that anemia, and nutrition for that matter, do not operate in isolation. The tool is not meantot be used at the household/community level. This is where a tool like a modified Root Cause Assessment tool could be complementary.
Additionally, in Ghana, at the request of the Ghana Health Service, we are training CHWs (who are GHS employees, to be differentiated from the Community Health Volunteers) on the various ways they can help, in course of their normal duties at the health facility and community level, in reducing anemia. Our training package overlaps with, and amplifies, other training that they have received from different national programs - MICYN, malaria, WASH etc. We also have modules where CHWs talk to the CHVs (who are, from some accounts, also overburdened) on how they can help. There is cross-pollination in the learning from the the two kinds of training in Ghana. We are waiting to hear about its impact.

Connie Gates Replied at 1:20 PM, 16 Jun 2017

Sorry I am late at contributing to these conversations, and I’m in India now so it’s after 10pm my time – not my most ‘productive’ brain functioning, but I did want to write something, on most of the topics, but hope that just writing in a few of them, everyone will be able to read. And it’s my first time participating in GHDonline.

I work with the Comprehensive Rural Health Project, Jamkhed, India, started by Drs Raj & Mabelle Arole in 1970. In the early 1970s, they had organized men’s groups in various villages; they had placed ANMs in the villages to provide primary health care, but that didn’t work out because the ANMs were not accepted by the villagers. So what to do? The men asked the Aroles if one of their women couldn’t be trained to help with improving health in their communities. In the early 1970s women were illiterate, and the Aroles weren’t sure how much they could learn, but thought they could at least help with nutrition and other health education. Once they started working with these women, they were amazed at how eager they wanted to learn, how capable they were, and how motivated they were to share their knowledge and skills with others in their villages.

http://jamkhed.org/programs/village-health-workers/

Lessons learned:
Selection is important – by the community in discussion with the mobile health team – characteristics like being socially minded, willing to work with the poor and low caste, compassion, experience as a mother. They provide leadership in their communities on a volunteer basis. They do not consider their work as a ‘job’ but as contributing to the well-being of their community.

Retention – very few VHWs have left their role, usually due to death or moving. They are so motivated based on the impact they see in their communities.
Role – they are volunteers, key change agents. They work on issues that the community identifies and analyzes together with the staff. They deal with root causes (determinants) as well as provide health care. Through prevention, early detection, treatment including home remedies and herbal medicines, case management, rehabilitation – most health problems. Their activities are based on the identified needs of the community, and the community groups learn from them and support their work. They are volunteer lay professionals. They are key to addressing problems that require behavior change, esp. re culture. When they learn in their training about something new, they will try it on themselves and their family first as role models, know CRHP staff will support them and reinforce the ‘message’. They are part of the health team, with referrals and follow up back and forth. Social issues are addressed, e.g. caste system, women’s status, harmful traditional beliefs/practices. CRHP does not require them to take on additional tasks – they do what their community wants/needs and is willing to be engaged in. So it is not a full-time ‘job’ that is directed by CRHP.

Daniel Palazuelos Panelist Replied at 12:04 AM, 17 Jun 2017

Thank you everyone for your contributions, and thank you Connie for joining to represent Jamkhed. It has been a pleasure to learn from all of you.

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.