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.
Link leads to: https://en.wikipedia.org/wiki/5-SPICE_framework