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What modifications are required to make the implementation of CHW programs feasible in urban and peri-urban slums as well as rural settings?

Posted: 15 Jun, 2017     Replies: 8

Community Health Worker (CHW) programs have been traditionally thought of as targeted to rural settings, although this is not explicitly stated in most in country CHW programs. What are the modifications required for a generic CHW programs to be implemented feasibly in urban and peri-urban slums as well as rural settings. Some key differences might include: the need for a physical structure for the CHW to work in, the availability/willingness of community members to volunteer, and prevalence of non-communicable health issues amongst.



Daniel Palazuelos Panelist Replied at 10:35 PM, 15 Jun 2017

This is a very good question. CHWs will be an important addition to health systems in any context, not only rural areas and I would add not only slums; I often wish I grew up in suburban New York City with a community health worker, as there was so much need not being being addressed by the traditional health system of doctors, nurses, and health educators in my school.

But in terms of making adaptations to program plans so that the programs will be appropriate for each context, I will refer you to my original post on how to design a CHW program. It is all about how their tasks contribute to the production of high-value outcomes, and how those efforts integrate into the larger health system. This helps guide the vision of how to start, but the specifics can take many different forms.

The conversations in this panel have been incredibly robust, and I highly recommend that you look back at a few of them for ideas on all the forms that a CHW program can take to address the local need, and be appropriate for that context. Let me point out a few that jumped out at me:

Urban: Elsa Haag has described how City Health Works in Harlem, New York City is addressing chronic illness among vulnerable people through health coaching and care coordination.
Urban: The Penn Center for community health workers' IMPaCT model is a key example of how another group of CHWs in an urban setting can help reach patients in ways that simply was not happening before. The results they are measuring show better outcomes and cost savings, but also a new vision on how medical care can be delivered in the US.
Rural: The team from Muso has described how a really well-designed project in rural Mali can achieve unprecedented reductions in under five mortality. Please pay special note that they do this specifically by NOT having the community health workers stationed in the health post, but rather by having them actively finding patients and treating them in their homes.
Rural: Isha Nirola describes how Possible has been able to create robust systems of care in Nepal that are strengthened by CHWs, but that also strengthen CHW efforts by building systems that deliver and measure impact.

Regardless of the model, it will be key to work towards achieving high standards of program design (as out lined in CHW AIM) and coordination across all actors in-country (as outlined by the CHW "Principles of Practice" document) - thank you Polly Walker for sharing these with us!

And of course, you can always refer to the encyclopedia of all things CHWs: the mCHIP Reference Guide (link below)

I hope this helps, and good luck!

Attached resource:

Youssouf Keita Panelist Replied at 7:18 AM, 16 Jun 2017

Merci a Acchi Sabogu pour avoir soulevé cette question et a Daniel pour la très bonne contribution.
Une chose aussi qui est faisable est d’essayé de trouver un modèle qui peut être utilisable tant pour les sites urbains que pour les sites ruraux.

Je partage ici avec vous notre expérience: Muso intervient présentement dans une zone péri urbaine (Depuis 12 ans et a commencé l’utilisation des CHW depuis 10 ans) et dans une zone rurale (Depuis un peu plus d'une année).
Dans les deux cas (milieu rural ou péri urbain) nous avons constaté que au Mali, les barrières d’accès aux soins sont en majeur partie similaires avec certes des degrés différents.

Notre ONG met en oeuvre dans les deux sites un même modèle de santé qui comprend 4 axes principaux qui sont:

1. La recherche proactive des cas : assurée par les Agents de Santé Communautaire (CHW) et les membres de la communauté à travers des visites à domicile (VAD) journalières afin de prodiguer des Soins Essentiels Communautaires (SEC) et/ou référer/accompagner vers une structure sanitaire le plus tôt que possible.
2. Les Soins Essentiels Communautaires (SEC) à domicile : Les CHW offrent le paquet de soins essentiels.
3. L’accès rapide aux structures sanitaires : Les patients qui ont besoins de soins sont amenés le plus tôt que possible dans un centre de santé.
4. La prise en charge sans frais : Pour assurer l’accès rapide et universel aux soins, le modèle de Muso lève la barrière financière pour accéder aux soins, organise les formations de renforcement de capacité du personnel soignant, fait la réhabilitation, l’équipement et la construction des infrastructures sanitaires.
Cet modèle avec ces différents axes sont valables tant pour le site urbain que pour un site rural.

En 2013, le modèle Muso a été testé dans une zone péri urbaine du district sanitaire de la commune VI de Bamako (capitale du Mali) par le Programme National de Lutte Contre le Paludisme (PNLP) du Ministère de la Santé du Mali, l’Université de Harvard et l’Université de Californie San Francisco.
Les chercheurs ont conduit une étude cross-sectionnelle. Ils ont enquêté un échantillon randomisé des domiciles au départ de 12 mois, 24 mois et 36 mois. L’étude a enregistré le taux de mortalité des enfants de moins de cinq (5) ans, avant et chaque année après la mise en œuvre du système des soins proactif de Muso.
Trois (3) ans après l’intervention de Muso, le taux de mortalité des enfants de moins de cinq (5) ans a été réduit d’environ dix (10) fois : de 15.5 % au départ de 1.7 % après trois ans d'intervention.
Ce résultat permet de conclure que les programmes de CHW sont autant nécessaire en milieu rural qu'en milieu péri urbain dont les caractéristique computationnelles sont a peu près les mêmes dans les pays en voie de développement comme le Mali.

Une grande étude contrôlée randomisée est en cours en milieu rural qui évaluera l'impact du modèle de santé de Muso sur la mortalité infantile et maternelle et plus d'autres indicateurs.

Trouvez ci dessous le lien d’accès a l'article qui a été publié sur PLOS One.

Jim Lloyd Panelist Replied at 9:33 AM, 16 Jun 2017

Daniel's examples here are excellent, and I'd additionally point to:

1. Johns Hopkins Community Health Partnership program,, which uses CHWs to coordinate care for people in East Baltimore;
2. The Camden Coalition of Healthcare Providers,, which is focused on identifying and serving high-need, high-cost patients in an urban area; and
3. The Los Angeles County Care Connections Program,, which is run in part by Drs. Behforouz & Hong, with whom we work and who have posted here.

I think an interesting point brought up by your post is that in the U.S., the opposite discussion is happening. Due to the particular needs of the populations and the economic and geographic contexts, CHW programs have usually been based in urban areas, and are now grappling with the challenges of doing this kind of work in rural or frontier settings.


Ari Johnson Panelist Replied at 10:27 AM, 16 Jun 2017

Thanks for raising this important question. As noted by Dan, Youssouf, and Jim, several programs have provided case studies for the potential impact of CHWs in rural and urban settings. In examining the literature, we see there is an important gap here--we have much more to learn about how to optimize CHW:population and supervisor:CHW ratios for example in rural vs. urban settings.

As Youssouf notes, our team has partnered with Ministry of Health colleagues to deploy CHWs in both rural and urban settings in Mali. We have found that one major difference to consider in planning resides in the dynamics of population growth. Amid rapid urbanization occurring across sub-Saharan Africa and around the world, cities, and particularly urban slum areas, have been growing rapidly. The pace of urban population growth has important implications for planning and deployment of CHWs. These areas may require frequent reassessments of their population, careful measurement of the pace of population growth, and frequent re-planning of CHW HR and supply chain needs accordingly. If the number of CHWs deployed to given urban areas remains flat during, for example, a five-year strategic plan as the population of those areas grow, those CHWs are likely to become overwhelmed by the rapid growth in the number of patients they are each asked to serve. We have in our experience also seen a chronic underestimation of the commodity (medication and supply) needs for government health care delivery in urban areas based on outdated population estimates.

More research is needed here, particularly to guide optimal staffing ratios for deploying CHWs and supervisors. A question for the GHD community: Are you aware of groups conducting research currently on optimal CHW:population ratios in different contexts?

Kassimu Tani Replied at 2:24 PM, 16 Jun 2017

The most important thing is to select community member who are interested and selected by members to work in their area. this will reduce retention as they are familiar with the setting they are working

Isha Nirola Panelist Replied at 5:49 PM, 16 Jun 2017

Thanks for these wonderful comments and interesting discussion. Another example of an "urban" CHW program that comes to mind is the Commonwealth Care Alliance in Boston (, which focuses on dual eligibility patients (Medicaid and Medicare) in Boston. Thus focusing on higher risk communities in an urban area. I've often thought that many of our patients in rural Nepal, would likely be considered "dual eligibility" in America because they face perils we often see when poverty and long term illness intersect (one often perpetuating the other).

Anthony Kullah Replied at 3:35 PM, 17 Jun 2017

Good piece. Thanks

Mohammed Qeshta Replied at 5:17 PM, 17 Jun 2017

Yes, I agree.

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.